%0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e71844 %T Knowledge Mapping and Global Trends in Simulation in Medical Education: Bibliometric and Visual Analysis %A Ba,Hongjun %A Zhang,Lili %A He,Xiufang %A Li,Shujuan %+ Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou, 510080, China, 86 15920109625, bahj3@mail.sysu.edu.cn %K medical education %K simulation-based teaching %K bibliometrics %K visualization analysis %K knowledge mapping %D 2025 %7 26.3.2025 %9 Original Paper %J JMIR Med Educ %G English %X Background: With the increasing recognition of the importance of simulation-based teaching in medical education, research in this field has developed rapidly. To comprehensively understand the research dynamics and trends in this area, we conducted an analysis of knowledge mapping and global trends. Objective: This study aims to reveal the research hotspots and development trends in the field of simulation-based teaching in medical education from 2004 to 2024 through bibliometric and visualization analyses. Methods: Using CiteSpace and VOSviewer, we conducted bibliometric and visualization analyses of 6743 articles related to simulation-based teaching in medical education, published in core journals from 2004 to 2024. The analysis included publication trends, contributions by countries and institutions, author contributions, keyword co-occurrence and clustering, and keyword bursts. Results: From 2004 to 2008, the number of articles published annually did not exceed 100. However, starting from 2009, the number increased year by year, reaching a peak of 850 articles in 2024, indicating rapid development in this research field. The United States, Canada, the United Kingdom, Australia, and China published the most articles. Harvard University emerged as a research hub with 1799 collaborative links, although the overall collaboration density was low. Among the 6743 core journal articles, a total of 858 authors were involved, with Lars Konge and Adam Dubrowski being the most prolific. However, collaboration density was low, and the collaboration network was relatively dispersed. A total of 812 common keywords were identified, forming 4189 links. The keywords “medical education,” “education,” and “simulation” had the highest frequency of occurrence. Cluster analysis indicated that “cardiopulmonary resuscitation” and “surgical education” were major research hotspots. From 2004 to 2024, a total of 20 burst keywords were identified, among which “patient simulation,” “randomized controlled trial,” “clinical competence,” and “deliberate practice” had high burst strength. In recent years, “application of simulation in medical education,” “3D printing,” “augmented reality,” and “simulation training” have become research frontiers. Conclusions: Research on the application of simulation-based teaching in medical education has become a hotspot, with expanding research areas and hotspots. Future research should strengthen interinstitutional collaboration and focus on the application of emerging technologies in simulation-based teaching. %R 10.2196/71844 %U https://mededu.jmir.org/2025/1/e71844 %U https://doi.org/10.2196/71844 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57057 %T Impact of a 3-Month Recall Using High-Fidelity Simulation or Screen-Based Simulation on Learning Retention During Neonatal Resuscitation Training for Residents in Anesthesia and Intensive Care: Randomized Controlled Trial %A Louvel,Anne-Claire %A Dopff,Cécile %A Loron,Gauthier %A Michelet,Daphne %K screen-based simulation %K high-fidelity simulation %K neonatal resuscitation %K pediatric %K infant %K neonatal %K newborns %K emergency %K urgent %K simulation %K resuscitation %K intensive care %K medical education %K anesthesia %K anesthesiology %K high fidelity %K educational %K student %K resident %K knowledge retention %K learner %K teaching %K intensive care unit %K ICU %D 2025 %7 21.3.2025 %9 %J JMIR Serious Games %G English %X Background: Retention capacities are dependent on the learning context. The optimal interval between two learning sessions to maintain a learner’s knowledge is often a subject of discussion, along with the methodology being used. Screen-based simulation could represent an easy alternative for retraining in neonatal resuscitation. Objective: The aim of the study was to evaluate the benefits of a 3-month recall session using high-fidelity simulation or screen-based simulation, assessed 6 months after an initial neonatal resuscitation training session among anesthesia and intensive care residents. Methods: All participating anesthesia and intensive care residents were volunteers, and they underwent training in the same session, which included a theoretical course and high-fidelity simulation. The attendees were then randomized into three groups: one with no 3-month recall, one with a high-fidelity simulation recall, and one with a screen-based simulation recall. To reassess the skills of each participant, a high-fidelity simulation was performed at 6 months. The primary outcomes included expert assessment of technical skills using the Neonatal Resuscitation Performance Evaluation score and nontechnical skills assessed by the Anesthesia Non-Technical Skills score. Secondary outcomes included a knowledge quiz and self-assessment of confidence. We compared the results between groups and analyzed intragroup progressions. Results: Twenty-eight participants were included in the study. No significant differences were observed between groups at the 6-month evaluation. However, we observed a significant improvement in theoretical knowledge and self-confidence among students over time. Regarding nontechnical skills, as evaluated by the Anesthesia Non-Technical Skills score, there was significant improvement between the initial training and the 6-month session in both recall groups (16 vs 12.8, P=.01 in the high-fidelity group; 16 vs 13.9, P=.05 in the simulation group; 14.7 vs 15.1, P=.50 in the control group). For technical skills assessed by the Neonatal Resuscitation Performance Evaluation score, a nonsignificant trend toward improvement was observed in the two recall groups, while a regression was observed in the control group (all Ps>.05). The increase in students’ self-confidence was significant across all groups but remained higher in the two 3-month recall groups. Conclusions: Initial neonatal resuscitation training for anesthesia and intensive care residents leads to improved knowledge and self-confidence that persist at 6 months. A 3-month recall session, whether through high-fidelity simulation or screen-based simulation, improves nontechnical skills (eg, situation management and team communication) and technical skills. Screen-based simulation, which saves time and resources, appears to be an effective educational method for recall after initial training. The study outcomes justify the need for further studies with larger sample sizes to confirm the promising role of serious games in educational programs for medical students. %R 10.2196/57057 %U https://games.jmir.org/2025/1/e57057 %U https://doi.org/10.2196/57057 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e67673 %T Demonstrating Tactical Combat Casualty Care in Simulated Environments to Enable Passive, Autonomous Documentation: Protocol for a Prospective Simulation-Based Study %A Little,Jeanette R %A Rivera-Nichols,Triana %A Pavliscsak,Holly H %A Badawi,Omar %A Gaudaen,James C %A Yeoman,Chevas R %A Hall,Todd S %A Quist,Ethan T %A Stoor-Burning,Ericka L %+ , The Telemedicine and Advanced Technology Research Center, 1054 Patchel Street, Fort Detrick, MD, 30905-5650, United States, 1 (706) 787 2394, jeanette.r.little.civ@health.mil %K tactical combat casualty care %K TCCC, automation %K medical documentation %K DD form 1380 %K combat casualty care %K artificial intelligence %K AI %K machine learning %K ML %K point of injury %K POI %K simulation %K military health %K passive data collection %K sensors %K algorithms %K medical record %D 2025 %7 17.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: The Telemedicine & Advanced Technology Research Center (TATRC) commenced a new research portfolio specifically addressing Autonomous Casualty Care (AC2) in 2023. The first project within this portfolio addresses the current and historical challenges of capturing tactical combat casualty care (TCCC) data in operational settings. Objective: The initial autonomous casualty care effort, the Passive Data Collection using Autonomous Documentation research project, conducts systematic, simulated patient and casualty care scenarios, leveraging suites of passive sensor inputs to populate a data repository that will automate future combat care. Methods: To obtain the required datasets, TATRC will engage care provider participants who provided consent in one of 6 randomized simulated TCCC scenarios leveraging an institutional review board–approved office protocol (#M-11057). These simulations will leverage mannikins (low and high fidelity) and live simulated patients (eg, human actors who provided consent). All consenting participants (eg, both the care providers and live simulated patients) will be equipped with suites of sensors that will passively collect data on care delivery actions and patient physiology. Simulated data is being collected at Fort Detrick, Maryland; Fort Sam Houston, Texas; Fort Indiantown Gap, Pennsylvania; Fort Liberty, North Carolina; and a commercial site in Greenville, North Carolina. Results: Across all research locations, TATRC will collect and annotate approximately 2500 simulation procedures tasks by March 2025. These study data will generate the first machine learning and artificial intelligence algorithms to populate Department of Defense (DD) Form 1380 fields accurately and reliably. Additional data collected past March 2025 will be used to continue to refine and mature the algorithm. Conclusions: The military health care system (MHS) lacks real-world datasets for TCCC care at the point of injury. Developing a data repository of simulated TCCC data is required as an essential step toward automating TCCC care. If TATRC’s research efforts result in the ability to automate care delivery documentation, this will alleviate the cognitive burden of TCCC care providers in austere, chaotic environments. By generating a TCCC data repository through this Autonomous Documentation research project, TATRC will have opportunities to leverage this research data to create machine learning and artificial intelligence models to advance passive, automated medical documentation across the health care continuum. International Registered Report Identifier (IRRID): DERR1-10.2196/67673 %M 40096684 %R 10.2196/67673 %U https://www.researchprotocols.org/2025/1/e67673 %U https://doi.org/10.2196/67673 %U http://www.ncbi.nlm.nih.gov/pubmed/40096684 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e62803 %T Exploring the Role of Immersive Virtual Reality Simulation in Health Professions Education: Thematic Analysis %A Talan,Jordan %A Forster,Molly %A Joseph,Leian %A Pradhan,Deepak %K virtual reality %K medical education %K virtual reality simulation %K extended reality %K simulation %K VR %K health professions education %K health education %K thematic analysis %K evolving technology %K qualitative study %K qualitative %K semistructured interviews %K educational experiences %K theoretical framework %D 2025 %7 12.3.2025 %9 %J JMIR Med Educ %G English %X Background: Although technology is rapidly advancing in immersive virtual reality (VR) simulation, there is a paucity of literature to guide its implementation into health professions education, and there are no described best practices for the development of this evolving technology. Objective: We conducted a qualitative study using semistructured interviews with early adopters of immersive VR simulation technology to investigate use and motivations behind using this technology in educational practice, and to identify the educational needs that this technology can address. Methods: We conducted 16 interviews with VR early adopters. Data were analyzed via directed content analysis through the lens of the Unified Theory of Acceptance and Use of Technology. Results: The main themes that emerged included focus on cognitive skills, access to education, resource investment, and balancing immersion. These findings help to clarify the intended role of VR simulation in health professions education. Based on our data, we synthesized a set of research questions that may help define best practices for future VR development and implementation. Conclusions: Immersive VR simulation technology primarily serves to teach cognitive skills, expand access to educational experiences, act as a collaborative repository of widely relevant and diverse simulation scenarios, and foster learning through deep immersion. By applying the Unified Theory of Acceptance and Use of Technology theoretical framework to the context of VR simulation, we not only collected validation evidence for this established theory, but also proposed several modifications to better explain use behavior in this specific setting. %R 10.2196/62803 %U https://mededu.jmir.org/2025/1/e62803 %U https://doi.org/10.2196/62803 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e66821 %T Augmenting Insufficiently Accruing Oncology Clinical Trials Using Generative Models: Validation Study %A El Kababji,Samer %A Mitsakakis,Nicholas %A Jonker,Elizabeth %A Beltran-Bless,Ana-Alicia %A Pond,Gregory %A Vandermeer,Lisa %A Radhakrishnan,Dhenuka %A Mosquera,Lucy %A Paterson,Alexander %A Shepherd,Lois %A Chen,Bingshu %A Barlow,William %A Gralow,Julie %A Savard,Marie-France %A Fesl,Christian %A Hlauschek,Dominik %A Balic,Marija %A Rinnerthaler,Gabriel %A Greil,Richard %A Gnant,Michael %A Clemons,Mark %A El Emam,Khaled %+ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 75 Laurier Ave E, Ottawa, ON, K1N 6N5, Canada, 1 6137975412, kelemam@ehealthinformation.ca %K generative models %K study accrual %K recruitment %K clinical trial replication %K oncology %K validation %K simulated patient %K simulation %K retrospective %K dataset %K patient %K artificial intelligence %K machine learning %D 2025 %7 5.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Insufficient patient accrual is a major challenge in clinical trials and can result in underpowered studies, as well as exposing study participants to toxicity and additional costs, with limited scientific benefit. Real-world data can provide external controls, but insufficient accrual affects all arms of a study, not just controls. Studies that used generative models to simulate more patients were limited in the accrual scenarios considered, replicability criteria, number of generative models, and number of clinical trials evaluated. Objective: This study aimed to perform a comprehensive evaluation on the extent generative models can be used to simulate additional patients to compensate for insufficient accrual in clinical trials. Methods: We performed a retrospective analysis using 10 datasets from 9 fully accrued, completed, and published cancer trials. For each trial, we removed the latest recruited patients (from 10% to 50%), trained a generative model on the remaining patients, and simulated additional patients to replace the removed ones using the generative model to augment the available data. We then replicated the published analysis on this augmented dataset to determine if the findings remained the same. Four different generative models were evaluated: sequential synthesis with decision trees, Bayesian network, generative adversarial network, and a variational autoencoder. These generative models were compared to sampling with replacement (ie, bootstrap) as a simple alternative. Replication of the published analyses used 4 metrics: decision agreement, estimate agreement, standardized difference, and CI overlap. Results: Sequential synthesis performed well on the 4 replication metrics for the removal of up to 40% of the last recruited patients (decision agreement: 88% to 100% across datasets, estimate agreement: 100%, cannot reject standardized difference null hypothesis: 100%, and CI overlap: 0.8-0.92). Sampling with replacement was the next most effective approach, with decision agreement varying from 78% to 89% across all datasets. There was no evidence of a monotonic relationship in the estimated effect size with recruitment order across these studies. This suggests that patients recruited earlier in a trial were not systematically different than those recruited later, at least partially explaining why generative models trained on early data can effectively simulate patients recruited later in a trial. The fidelity of the generated data relative to the training data on the Hellinger distance was high in all cases. Conclusions: For an oncology study with insufficient accrual with as few as 60% of target recruitment, sequential synthesis can enable the simulation of the full dataset had the study continued accruing patients and can be an alternative to drawing conclusions from an underpowered study. These results provide evidence demonstrating the potential for generative models to rescue poorly accruing clinical trials, but additional studies are needed to confirm these findings and to generalize them for other diseases. %M 40053790 %R 10.2196/66821 %U https://www.jmir.org/2025/1/e66821 %U https://doi.org/10.2196/66821 %U http://www.ncbi.nlm.nih.gov/pubmed/40053790 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63312 %T Virtual Patient Simulations Using Social Robotics Combined With Large Language Models for Clinical Reasoning Training in Medical Education: Mixed Methods Study %A Borg,Alexander %A Georg,Carina %A Jobs,Benjamin %A Huss,Viking %A Waldenlind,Kristin %A Ruiz,Mini %A Edelbring,Samuel %A Skantze,Gabriel %A Parodis,Ioannis %+ Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, and Center for Molecular Medicine (CMM), D2:01 Rheumatology Karolinska University Hospital Solna, Stockholm, SE-171 76, Sweden, 46 722321322, ioannis.parodis@ki.se %K virtual patients %K clinical reasoning %K large language models %K social robotics %K medical education %K sustainable learning %K medical students %D 2025 %7 3.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual patients (VPs) are computer-based simulations of clinical scenarios used in health professions education to address various learning outcomes, including clinical reasoning (CR). CR is a crucial skill for health care practitioners, and its inadequacy can compromise patient safety. Recent advancements in large language models (LLMs) and social robots have introduced new possibilities for enhancing VP interactivity and realism. However, their application in VP simulations has been limited, and no studies have investigated the effectiveness of combining LLMs with social robots for CR training. Objective: The aim of the study is to explore the potential added value of a social robotic VP platform combined with an LLM compared to a conventional computer-based VP modality for CR training of medical students. Methods: A Swedish explorative proof-of-concept study was conducted between May and July 2023, combining quantitative and qualitative methodology. In total, 15 medical students from Karolinska Institutet and an international exchange program completed a VP case in a social robotic platform and a computer-based semilinear platform. Students’ self-perceived VP experience focusing on CR training was assessed using a previously developed index, and paired 2-tailed t test was used to compare mean scores (scales from 1 to 5) between the platforms. Moreover, in-depth interviews were conducted with 8 medical students. Results: The social robotic platform was perceived as more authentic (mean 4.5, SD 0.7 vs mean 3.9, SD 0.5; odds ratio [OR] 2.9, 95% CI 0.0-1.0; P=.04) and provided a beneficial overall learning effect (mean 4.4, SD 0.6 versus mean 4.1, SD 0.6; OR 3.7, 95% CI 0.1-0.5; P=.01) compared with the computer-based platform. Qualitative analysis revealed 4 themes, wherein students experienced the social robot as superior to the computer-based platform in training CR, communication, and emotional skills. Limitations related to technical and user-related aspects were identified, and suggestions for improvements included enhanced facial expressions and VP cases simulating multiple personalities. Conclusions: A social robotic platform enhanced by an LLM may provide an authentic and engaging learning experience for medical students in the context of VP simulations for training CR. Beyond its limitations, several aspects of potential improvement were identified for the social robotic platform, lending promise for this technology as a means toward the attainment of learning outcomes within medical education curricula. %M 40053778 %R 10.2196/63312 %U https://www.jmir.org/2025/1/e63312 %U https://doi.org/10.2196/63312 %U http://www.ncbi.nlm.nih.gov/pubmed/40053778 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e66478 %T Novel Evaluation Metric and Quantified Performance of ChatGPT-4 Patient Management Simulations for Early Clinical Education: Experimental Study %A Scherr,Riley %A Spina,Aidin %A Dao,Allen %A Andalib,Saman %A Halaseh,Faris F %A Blair,Sarah %A Wiechmann,Warren %A Rivera,Ronald %K medical school simulations %K AI in medical education %K preclinical curriculum %K ChatGPT %K ChatGPT-4 %K medical simulation %K simulation %K multimedia %K feedback %K medical education %K medical student %K clinical education %K pilot study %K patient management %D 2025 %7 27.2.2025 %9 %J JMIR Form Res %G English %X Background: Case studies have shown ChatGPT can run clinical simulations at the medical student level. However, no data have assessed ChatGPT’s reliability in meeting desired simulation criteria such as medical accuracy, simulation formatting, and robust feedback mechanisms. Objective: This study aims to quantify ChatGPT’s ability to consistently follow formatting instructions and create simulations for preclinical medical student learners according to principles of medical simulation and multimedia educational technology. Methods: Using ChatGPT-4 and a prevalidated starting prompt, the authors ran 360 separate simulations of an acute asthma exacerbation. A total of 180 simulations were given correct answers and 180 simulations were given incorrect answers. ChatGPT was evaluated for its ability to adhere to basic simulation parameters (stepwise progression, free response, interactivity), advanced simulation parameters (autonomous conclusion, delayed feedback, comprehensive feedback), and medical accuracy (vignette, treatment updates, feedback). Significance was determined with χ² analyses using 95% CIs for odds ratios. Results: In total, 100% (n=360) of simulations met basic simulation parameters and were medically accurate. For advanced parameters, 55% (200/360) of all simulations delayed feedback, while the Correct arm (157/180, 87%) delayed feedback was significantly more than the Incorrect arm (43/180, 24%; P<.001). A total of 79% (285/360) of simulations concluded autonomously, and there was no difference between the Correct and Incorrect arms in autonomous conclusion (146/180, 81% and 139/180, 77%; P=.36). Overall, 78% (282/360) of simulations gave comprehensive feedback, and there was no difference between the Correct and Incorrect arms in comprehensive feedback (137/180, 76% and 145/180, 81%; P=.31). ChatGPT-4 was not significantly more likely to conclude simulations autonomously (P=.34) and provide comprehensive feedback (P=.27) when feedback was delayed compared to when feedback was not delayed. Conclusions: These simulations have the potential to be a reliable educational tool for simple simulations and can be evaluated by a novel 9-part metric. Per this metric, ChatGPT simulations performed perfectly on medical accuracy and basic simulation parameters. It performed well on comprehensive feedback and autonomous conclusion. Delayed feedback depended on the accuracy of user inputs. A simulation meeting one advanced parameter was not more likely to meet all advanced parameters. Further work must be done to ensure consistent performance across a broader range of simulation scenarios. %R 10.2196/66478 %U https://formative.jmir.org/2025/1/e66478 %U https://doi.org/10.2196/66478 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e47150 %T The Design and Evaluation of a Simulation Tool for Audiology Screening Education: Design Science Approach %A Gerdes,John %A Schooley,Benjamin %A Sharp,Dakota %A Miller,Juliana %+ Department of Integrated Information Technology, University of South Carolina, Bert Storey Innovation Center, Suite 1300, 550 Assembly Street, Columbia, SC, 29208, United States, 1 803 777 8529, jgerdes@sc.edu %K design science %K audiology %K simulation %K hearing screening %K framework %K speech pathology %K training %D 2025 %7 20.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: The early identification of hearing loss and ear disorders is important. Regular screening is recommended for all age groups to determine whether a full hearing assessment is necessary and allow for timely treatment of hearing problems. Procedural training is needed for new speech-language pathology students as well as continuing education for those trained to perform this screening procedure. Limited availability and access to physical training locations can make it difficult to receive the needed training. Objective: The aims of this study were to (1) develop a new hearing screening simulation software platform and (2) assess its effectiveness in training a group of graduate-level speech-language pathology students in hearing screening procedures. Methods: An audiology simulator modeled after the commercial Grason-Stadler GSI39 combination audiometer and tympanometer device was developed to serve as a precursor to traditional face-to-face clinical instruction. A description of the simulator development process, guided by a design science approach, is presented. The initiation phase established the initial criteria for the simulator design. This was followed by an iterative process involving prototype development, review, and critique by the clinical faculty. This feedback served as input for the subsequent iteration. The evaluation of the final prototype involved 33 speech-language pathology graduate students as part of an introductory audiology class. These students were randomly assigned to control (receiving in-person instruction) and test (in-person instruction and simulation tool use) groups. Students in both groups were subsequently evaluated as they performed audiology screenings on human participants and completed a 25-item pretest and posttest survey. Nonparametric Mann-Whitney U tests were conducted on the mean differences between pretest and posttest ordinal survey response data to compare the control and intervention groups. Results: The results indicated that the students who used the simulation tool demonstrated greater confidence in their ability to (1) explain hearing screening procedures to a child (P=.02), (2) determine whether otoscopy results are normal (P=.02), and (3) determine whether otoscopy results are abnormal (P=.03). Open-ended responses indicated that the students found that the hands-on experience provided by the simulator resulted in an easy-to-use and useful learning experience with the audiometer, which increased their confidence in their ability to perform hearing screenings. Conclusions: Software-based education simulation tools for audiology screening may provide a beneficial approach to educating students and professionals in hearing screening training. The tool tested in this study supports individualized, self-paced learning with context-sensitive feedback and performance assessment, incorporating an extensible approach to supporting simulated subjects. %M 39977027 %R 10.2196/47150 %U https://formative.jmir.org/2025/1/e47150 %U https://doi.org/10.2196/47150 %U http://www.ncbi.nlm.nih.gov/pubmed/39977027 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e69544 %T Advancing Health Care With Digital Twins: Meta-Review of Applications and Implementation Challenges %A Ringeval,Mickaël %A Etindele Sosso,Faustin Armel %A Cousineau,Martin %A Paré,Guy %+ HEC Montréal, 3000 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 2A7, Canada, 1 5143406000, mickael.ringeval@hec.ca %K digital twins %K meta-review %K health IT %K applications %K challenges %K healthcare innovation %K personalized medicine %K operational efficiency %D 2025 %7 19.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Digital twins (DTs) are digital representations of real-world systems, enabling advanced simulations, predictive modeling, and real-time optimization in various fields, including health care. Despite growing interest, the integration of DTs in health care faces challenges such as fragmented applications, ethical concerns, and barriers to adoption. Objective: This study systematically reviews the existing literature on DT applications in health care with three objectives: (1) to map primary applications, (2) to identify key challenges and limitations, and (3) to highlight gaps that can guide future research. Methods: A meta-review was conducted in a systematic fashion, adhering to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, and included 25 literature reviews published between 2021 and 2024. The search encompassed 5 databases: PubMed, CINAHL, Web of Science, Embase, and PsycINFO. Thematic synthesis was used to categorize DT applications, stakeholders, and barriers to adoption. Results: A total of 3 primary DT applications in health care were identified: personalized medicine, operational efficiency, and medical research. While current applications, such as predictive diagnostics, patient-specific treatment simulations, and hospital resource optimization, remain in their early stages of development, they highlight the significant potential of DTs. Challenges include data quality, ethical issues, and socioeconomic barriers. This review also identified gaps in scalability, interoperability, and clinical validation. Conclusions: DTs hold transformative potential in health care, providing individualized care, operational optimization, and accelerated research. However, their adoption is hindered by technical, ethical, and financial barriers. Addressing these issues requires interdisciplinary collaboration, standardized protocols, and inclusive implementation strategies to ensure equitable access and meaningful impact. %M 39969978 %R 10.2196/69544 %U https://www.jmir.org/2025/1/e69544 %U https://doi.org/10.2196/69544 %U http://www.ncbi.nlm.nih.gov/pubmed/39969978 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e58744 %T Simulation-Based Learning Supported by Technology to Enhance Critical Thinking in Nursing Students: Scoping Review %A Stenseth,Hege Vistven %A Steindal,Simen A %A Solberg,Marianne Trygg %A Ølnes,Mia Alexandra %A Sørensen,Anne Lene %A Strandell-Laine,Camilla %A Olaussen,Camilla %A Farsjø Aure,Caroline %A Pedersen,Ingunn %A Zlamal,Jaroslav %A Gue Martini,Jussara %A Bresolin,Paula %A Linnerud,Silje Christin Wang %A Nes,Andréa Aparecida Gonçalves %+ Department of Graduate Studies, Faculty of Nursing, Lovisenberg Diaconal University College, Lovisenbergata 15 B, Oslo, 0456, Norway, 47 93840198, hege.vistven@ldh.no %K critical thinking %K simulation-based learning %K technologically supported simulation-based learning %K nursing education %K nursing students %K review %D 2025 %7 18.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Critical thinking is a crucial skill in the nursing profession and must be fostered through nursing education. Simulation-based learning (SBL) with technological modalities is a pedagogical approach to enhance critical thinking skills for nursing students. The use of technology in SBL to achieve critical thinking skills is diverse. No previous scoping review has systematically mapped studies on SBL supported by technology to enhance critical thinking in nursing students. Objective: This scoping review aimed to systematically map research on the use of SBL supported by technology to enhance critical thinking in nursing students. Methods: This scoping review was conducted according to the framework by Arksey and O’Malley and was reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. A systematic, comprehensive literature search was performed in the LILACS, ERIC, MEDLINE, Embase, PsycINFO, and Web of Science databases in 2021 and repeated in 2023 and 2024. Pairs of authors independently assessed titles, abstracts, and full-text papers and extracted data from the included studies. The data underwent summative and thematic analysis and were categorized according to the findings. Results: In total, 4 main categories of technology applied in SBL were identified: computer-based simulations, human-patient simulators, virtual reality or immersive virtual reality, and others. The findings revealed a shift across time in the technology used for SBL to enhance critical thinking, from human patient simulators to computer-based simulations. A dominant part of the included studies published after 2018 (21/44, 48%) incorporated a combination of asynchronous and synchronous learning activities. The theoretical foundation of the studies revealed a range of scientific theories and conceptual frameworks and models. Enablers of or barriers to the enhancement of critical thinking skills in nursing students were identified within the following themes: affinity for and availability of technology, realism, accessibility, engagement and motivation, validation, return on investment, and enhanced critical thinking through SBL using technology. Conclusions: There has been a noticeable shift in the technology and use of technology in SBL. Descriptions of the applied technology and pedagogical considerations are pivotal for comparing or synthesizing research results. There has been a trend toward a blended educational approach combining synchronous and asynchronous learning activities. User technological proficiency and the perceived quality of the technology are imperative in the development of critical thinking. Realism, engagement, and motivation play pivotal roles in the enhancement of critical thinking in technologically supported SBL. The establishment of robust theoretical foundations of research and standardized research practices will strengthen the evidence obtained from the research conducted. %M 39965203 %R 10.2196/58744 %U https://www.jmir.org/2025/1/e58744 %U https://doi.org/10.2196/58744 %U http://www.ncbi.nlm.nih.gov/pubmed/39965203 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e68272 %T Enhancing Immersion in Virtual Reality–Based Advanced Life Support Training: Randomized Controlled Trial %A Kitapcioglu,Dilek %A Aksoy,Mehmet Emin %A Ozkan,Arun Ekin %A Usseli,Tuba %A Cabuk Colak,Dilan %A Torun,Tugrul %+ Center of Advanced Simulation and Education, Acibadem Mehmet Ali Aydinlar University, Kayisdagi cad No 32 Atasehir, Istanbul, 34752, Turkey, 90 05052685158, emin.aksoy@acibadem.edu.tr %K artificial intelligence %K voice recognition %K serious gaming %K immersion %K virtual reality %D 2025 %7 14.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious game–based training modules are pivotal for simulation-based health care training. With advancements in artificial intelligence (AI) and natural language processing, voice command interfaces offer an intuitive alternative to traditional virtual reality (VR) controllers in VR applications. Objective: This study aims to compare AI-supported voice command interfaces and traditional VR controllers in terms of user performance, exam scores, presence, and confidence in advanced cardiac life support (ACLS) training. Methods: A total of 62 volunteer students from Acibadem Mehmet Ali Aydinlar University Vocational School for Anesthesiology, aged 20-22 years, participated in the study. All the participants completed a pretest consisting of 10 multiple-choice questions about ACLS. Following the pretest, participants were randomly divided into 2 groups: the voice command group (n=31) and the VR controller group (n=31). The voice command group members completed the VR-based ACLS serious game in training mode twice, using an AI-supported voice command as the game interface. The VR controller group members also completed the VR-based ACLS serious game in training mode twice, but they used VR controllers as the game interface. The participants completed a survey to assess their level of presence and confidence during gameplay. Following the survey, participants completed the exam module of the VR-based serious gaming module. At the final stage of the study, participants completed a posttest, which had the same content as the pretest. VR-based exam scores of the voice command and VR controller groups were compared using a 2-tailed, independent-samples t test, and linear regression analysis was conducted to examine the effect of presence and confidence rating. Results: Both groups showed an improvement in performance from pretest to posttest, with no significant difference in the magnitude of improvement between the 2 groups (P=.83). When comparing presence ratings, there was no significant difference between the voice command group (mean 5.18, SD 0.83) and VR controller group (mean 5.42, SD 0.75; P=.25). However, when comparing VR-based exam scores, the VR controller group (mean 80.47, SD 13.12) significantly outperformed the voice command group (mean 66.70, SD 21.65; P=.005), despite both groups having similar time allocations for the exam (voice command group: mean 18.59, SD 5.28 minutes and VR controller group: mean 17.3, SD 4.83 minutes). Confidence levels were similar between the groups (voice command group: mean 3.79, SD 0.77 and VR controller group: mean 3.60, SD 0.72), but the voice command group displayed a significant overconfidence bias (voice command group: mean 0.09, SD 0.24 and VR controller group: mean –0.09, SD 0.18; P=.002). Conclusions: VR-based ACLS training demonstrated effectiveness; however, the use of voice commands did not result in improved performance. Further research should explore ways to optimize AI’s role in education through VR. Trial Registration: ClinicalTrials.gov NCT06458452; https://clinicaltrials.gov/ct2/show/NCT06458452 %M 39951703 %R 10.2196/68272 %U https://games.jmir.org/2025/1/e68272 %U https://doi.org/10.2196/68272 %U http://www.ncbi.nlm.nih.gov/pubmed/39951703 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e62688 %T Exploring Nursing Students’ Experiences of Empathy and User Experiences in an Immersive Virtual Reality Simulation Game: Cross-Sectional Study %A Koivisto,Jaana-Maija %A Kämäräinen,Sanna %A Mattsson,Katri %A Jumisko-Pyykkö,Satu %A Ikonen,Riikka %A Haavisto,Elina %+ Department of Public Health, Faculty of Medicine, University of Helsinki, PO Box 20, Helsinki, 00014, Finland, 358 503207111, jaana-maija.koivisto@helsinki.fi %K education %K nursing %K learning %K empathy %K virtual reality %K simulation %K user experience %K cross sectional %D 2025 %7 13.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Empathy is associated with better clinical outcomes and patient-care experiences, and it has been demonstrated that training can improve nursing students’ empathy. The use of virtual reality (VR) as an experiential learning strategy may increase the empathetic behavior of caregivers. Although much research exists on the use of VR in education, there is still little research on learning empathy in nursing education through immersive VR games that include a head-mounted display and hand controllers. In addition, it is important to study both learning and user experiences in nursing education that utilizes VR technology. Objective: This study aims to explore nursing students’ experiences of empathy and user experiences in an immersive VR simulation game. Methods: A cross-sectional design was used. A total of 52 graduating nursing students from 3 universities of applied sciences in Finland participated in the study. The immersive VR simulation game employed in the study was played with a head-mounted display and hand controllers. The instruments used were the Basic Empathy Scale in Adults (BES-A) before the VR simulation gaming session and the Comprehensive State Empathy Scale (CSES) and AttrakDiff 2.0 Scale after the session. Results: The students’ overall level of empathy experienced in the immersive VR simulation game was favorable (CSES; mean 2.9, SD 0.57). Participants who had a higher level of empathy (BES-A) before playing the immersive VR simulation game also experienced slightly more feelings of empathy after playing (CSES). However, the association between the measures was not statistically significant (r=0.187, P=.18). The overall empathy (CSES) experienced in the immersive VR simulation game was positively correlated with its subscales. The use of the VR simulation provided a positive user experience in all 4 factors of the AttrakDiff 2.0 Scale. Overall User Experience and Emotion Sharing correlated negatively (r=−0.248, P=.042), as did Attractiveness and Emotion Sharing (r=−0.327, P=.018). Hedonic Quality Stimulation correlated negatively with Cognitive Empathy (r=–0.279, P=.045). Conclusions: The results of this study indicate that the use of an immersive VR simulation game in nursing education as a means of increasing empathy seems promising and justified. The immersive VR simulation game offered positive user experiences, which further supported the idea of implementing it in education. However, more research is needed on what kinds of VR environments are the most effective in promoting empathy among nursing students. Furthermore, when using VR technology in learning, one should consider that the VR setting must not be too technical but rather simple, straightforward, and predictable. %M 39946691 %R 10.2196/62688 %U https://games.jmir.org/2025/1/e62688 %U https://doi.org/10.2196/62688 %U http://www.ncbi.nlm.nih.gov/pubmed/39946691 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e64780 %T Virtual Reality Simulation for Undergraduate Nursing Students for Care of Patients With Infectious Diseases: Mixed Methods Study %A Chang,Wen %A Lin,Chun-Chih %A Crilly,Julia %A Lee,Hui-Ling %A Chen,Li-Chin %A Han,Chin-Yen %+ Department of Nursing, Chang Gung University of Science and Technology, 261, Wenhua 1st Road, Guishan Dist., Taoyuan City, 33303, Taiwan, 886 3 2118999 ext 3417, cyhan@mail.cgust.edu.tw %K virtual reality %K infection control %K learning motivation %K learning attitudes %K nursing education %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality simulation (VRS) teaching offers nursing students a safe, immersive learning environment with immediate feedback, enhancing learning outcomes. Before the COVID-19 pandemic, nursing students had limited training and opportunities to care for patients in isolation units with infectious diseases. However, the pandemic highlighted the ongoing global priority of providing care for patients with infectious diseases. Objective: This study aims to (1) examine the effectiveness of VRS in preparing nursing students to care for patients with infectious diseases by assessing its impact on their theoretical knowledge, learning motivation, and attitudes; and (2) evaluate their experiences with VRS. Methods: This 2-phased mixed methods study recruited third-year undergraduate nursing students enrolled in the Integrated Emergency and Critical Care course at a university in Taiwan. Phase 1 used a quasi-experimental design to address objective 1 by comparing the learning outcomes of students in the VRS teaching program (experimental group) with those in the traditional teaching program (control group). Tools included an infection control written test, the Instructional Materials Motivation Survey, and a learning attitude questionnaire. The experimental group participated in a VRS lesson titled “Caring for a Patient with COVID-19 in the Negative Pressure Unit” as part of the infection control unit. In phase 2, semistructured interviews were conducted to address objective 2, exploring students’ learning experiences. Results: A total of 107 students participated in phase 1, and 18 students participated in phase 2. Both the VRS and control groups showed significant improvements in theoretical knowledge scores (for the VRS group t46=–7.47; P<.001, for the control group t59=–4.04; P<.001). However, compared with the control group, the VRS group achieved significantly higher theoretical knowledge scores (t98.13=2.70; P=.008) and greater learning attention (t105=2.30; P=.02) at T1. Additionally, the VRS group demonstrated a statistically significant higher regression coefficient for learning confidence compared with the control group (β=.29; P=.03). The students’ learning experiences in the VRS group were categorized into 4 themes: Applying Professional Knowledge to Patient Care, Enhancing Infection Control Skills, Demonstrating Patient Care Confidence, and Engaging in Real Clinical Cases. The core theme identified was Strengthening Clinical Patient Care Competencies. Conclusions: The findings suggest that VRS teaching significantly enhanced undergraduate nursing students’ infection control knowledge, learning attention, and confidence. Qualitative insights reinforced the quantitative results, highlighting the holistic benefits of VRS teaching in nursing education, including improved learning outcomes. The positive impact on student motivation and attitudes indicates a potentially transformative approach to nursing education, particularly in the post–COVID-19 era, where digital and remote learning tools play an increasingly vital role. %M 39933166 %R 10.2196/64780 %U https://mededu.jmir.org/2025/1/e64780 %U https://doi.org/10.2196/64780 %U http://www.ncbi.nlm.nih.gov/pubmed/39933166 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e60273 %T The Effects of Presenting AI Uncertainty Information on Pharmacists’ Trust in Automated Pill Recognition Technology: Exploratory Mixed Subjects Study %A Kim,Jin Yong %A Marshall,Vincent D %A Rowell,Brigid %A Chen,Qiyuan %A Zheng,Yifan %A Lee,John D %A Kontar,Raed Al %A Lester,Corey %A Yang,Xi Jessie %+ , Industrial and Operations Engineering, University of Michigan, 1640 IOE, 1205 Beal Avenue, Ann Arbor, MI, 48105, United States, 1 7347630541, xijyang@umich.edu %K artificial intelligence %K human-computer interaction %K uncertainty communication %K visualization %K medication errors %K safety %K artificial intelligence aid %K pharmacists %K pill verification %K automation %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Dispensing errors significantly contribute to adverse drug events, resulting in substantial health care costs and patient harm. Automated pill verification technologies have been developed to aid pharmacists with medication dispensing. However, pharmacists’ trust in such automated technologies remains unexplored. Objective: This study aims to investigate pharmacists’ trust in automated pill verification technology designed to support medication dispensing. Methods: Thirty licensed pharmacists in the United States performed a web-based simulated pill verification task to determine whether an image of a filled medication bottle matched a known reference image. Participants completed a block of 100 verification trials without any help, and another block of 100 trials with the help of an imperfect artificial intelligence (AI) aid recommending acceptance or rejection of a filled medication bottle. The experiment used a mixed subjects design. The between-subjects factor was the AI aid type, with or without an AI uncertainty plot. The within-subjects factor was the four potential verification outcomes: (1) the AI rejects the incorrect drug, (2) the AI rejects the correct drug, (3) the AI approves the incorrect drug, and (4) the AI approves the correct drug. Participants’ trust in the AI system was measured. Mixed model (generalized linear models) tests were conducted with 2-tailed t tests to compare the means between the 2 AI aid types for each verification outcome. Results: Participants had an average trust propensity score of 72 (SD 18.08) out of 100, indicating a positive attitude toward trusting automated technologies. The introduction of an uncertainty plot to the AI aid significantly enhanced pharmacists’ end trust (t28=–1.854; P=.04). Trust dynamics were influenced by AI aid type and verification outcome. Specifically, pharmacists using the AI aid with the uncertainty plot had a significantly larger trust increment when the AI approved the correct drug (t78.98=3.93; P<.001) and a significantly larger trust decrement when the AI approved the incorrect drug (t2939.72=–4.78; P<.001). Intriguingly, the absence of the uncertainty plot led to an increase in trust when the AI correctly rejected an incorrect drug, whereas the presence of the plot resulted in a decrease in trust under the same circumstances (t509.77=–3.96; P<.001). A pronounced “negativity bias” was observed, where the degree of trust reduction when the AI made an error exceeded the trust gain when the AI made a correct decision (z=–11.30; P<.001). Conclusions: To the best of our knowledge, this study is the first attempt to examine pharmacists’ trust in automated pill verification technology. Our findings reveal that pharmacists have a favorable disposition toward trusting automation. Moreover, providing uncertainty information about the AI’s recommendation significantly boosts pharmacists’ trust in AI aid, highlighting the importance of developing transparent AI systems within health care. %M 39932773 %R 10.2196/60273 %U https://humanfactors.jmir.org/2025/1/e60273 %U https://doi.org/10.2196/60273 %U http://www.ncbi.nlm.nih.gov/pubmed/39932773 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57297 %T Exploring Virtual Reality and Exercise Simulator Interventions in Patients With Attention Deficit Hyperactivity Disorder: Comprehensive Literature Review %A Sarai,Gurdeep %A Jayaraman,Prem Prakash %A Tirosh,Oren %A Wickramasinghe,Nilmini %+ School of Health Sciences, Swinburne University of Technology, 1 Almeida Cresent, Melbourne, 3141, Australia, 61 411362177, gurdeep.sarai@gmail.com %K exercise-based simulator %K exergame %K virtual reality %K physical activity %K attention-deficit/hyperactivity disorder %D 2025 %7 29.1.2025 %9 Review %J JMIR Serious Games %G English %X Background: This review explores virtual reality (VR) and exercise simulator–based interventions for individuals with attention-deficit/hyperactivity disorder (ADHD). Past research indicates that both VR and simulator-based interventions enhance cognitive functions, such as executive function and memory, though their impacts on attention vary. Objective: This study aimed to contribute to the ongoing scientific discourse on integrating technology-driven interventions into the management and evaluation of ADHD. It specifically seeks to consolidate findings on how VR and exercise simulators may support individuals with ADHD, acknowledging associated challenges and implications inherent in both technological approaches. Methods: This research looks at existing literature to examine the potential efficacy of VR and exercise simulator–based interventions for individuals with ADHD. It evaluates the capacity of these interventions to address specific challenges along with an emphasis on the adjustments for accommodating unique user behaviors. Additionally, it underscores the limited exploration of user perceptions of exercise simulator–based interventions and the undervalued role of motor function in both ADHD assessment and symptom management. Results: The findings of this scoping review reveal that, while these interventions enhance user motivation and enjoyment, certain challenges resist modification through technology. Furthermore, this study explores the intricate complexities involved in customizing these technologies to accommodate the diverse aspects of user behavior and highlights the potential limitations in the use of VR. Conclusions: This scoping review contributes to the ongoing research on enhancing interventions to support individuals with ADHD. It advocates for participant-centric approaches that aim to optimize both cognitive and motor outcomes while prioritizing the enhancement of user experiences. This study emphasizes the need for a comprehensive approach to interventions, recognizing the relationship between cognitive and motor abilities, and calls for improving technological interventions to address the varied needs of individuals with ADHD. %M 39879092 %R 10.2196/57297 %U https://games.jmir.org/2025/1/e57297 %U https://doi.org/10.2196/57297 %U http://www.ncbi.nlm.nih.gov/pubmed/39879092 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e57424 %T Barriers to and Facilitators of Implementing Team-Based Extracorporeal Membrane Oxygenation Simulation Study: Exploratory Analysis %A Brown,Joan %A De-Oliveira,Sophia %A Mitchell,Christopher %A Cesar,Rachel Carmen %A Ding,Li %A Fix,Melissa %A Stemen,Daniel %A Yacharn,Krisda %A Wong,Se Fum %A Dhillon,Anahat %K intensive care unit %K ICU %K teamwork in the ICU %K team dynamics %K collaboration %K interprofessional collaboration %K simulation %K simulation training %K ECMO %K extracorporeal membrane oxygenation %K life support %K cardiorespiratory dysfunction %K cardiorespiratory %K cardiology %K respiratory %K heart %K lungs %D 2025 %7 24.1.2025 %9 %J JMIR Med Educ %G English %X Introduction: Extracorporeal membrane oxygenation (ECMO) is a critical tool in the care of severe cardiorespiratory dysfunction. Simulation training for ECMO has become standard practice. Therefore, Keck Medicine of the University of California (USC) holds simulation-training sessions to reinforce and improve providers knowledge. Objective: This study aimed to understand the impact of simulation training approaches on interprofessional collaboration. We believed simulation-based ECMO training would improve interprofessional collaboration through increased communication and enhance teamwork. Methods: This was a single-center, mixed methods study of the Cardiac and Vascular Institute Intensive Care Unit at Keck Medicine of USC conducted from September 2021 to April 2023. Simulation training was offered for 1 hour monthly to the clinical team focused on the collaboration and decision-making needed to evaluate the initiation of ECMO therapy. Electronic surveys were distributed before, after, and 3 months post training. The survey evaluated teamwork and the effectiveness of training, and focus groups were held to understand social environment factors. Additionally, trainee and peer evaluation focus groups were held to understand socioenvironmental factors. Results: In total, 37 trainees attended the training simulation from August 2021 to August 2022. Using 27 records for exploratory factor analysis, the standardized Cronbach α was 0.717. The survey results descriptively demonstrated a positive shift in teamwork ability. Qualitative themes identified improved confidence and decision-making. Conclusions: The study design was flawed, indicating improvement opportunities for future research on simulation training in the clinical setting. The paper outlines what to avoid when designing and implementing studies that assess an educational intervention in a complex clinical setting. The hypothesis deserves further exploration and is supported by the results of this study. %R 10.2196/57424 %U https://mededu.jmir.org/2025/1/e57424 %U https://doi.org/10.2196/57424 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e69742 %T Advantages and Inconveniences of a Multi-Agent Large Language Model System to Mitigate Cognitive Biases in Diagnostic Challenges %A Bousquet,Cedric %A Beltramin,Divà %+ Laboratory of Medical Informatics and Knowledge Engineering in e-Health, Inserm, Sorbonne University, 15 rue de l'école de Médecine, Paris, F-75006, France, 33 0477127974, cedric.bousquet@chu-st-etienne.fr %K large language model %K multi-agent system %K diagnostic errors %K cognition %K clinical decision-making %K cognitive bias %K generative artificial intelligence %D 2025 %7 20.1.2025 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 39832364 %R 10.2196/69742 %U https://www.jmir.org/2025/1/e69742 %U https://doi.org/10.2196/69742 %U http://www.ncbi.nlm.nih.gov/pubmed/39832364 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e59850 %T Case-Based Virtual Reality Simulation for Severe Pelvic Trauma Clinical Skill Training in Medical Students: Design and Pilot Study %A Teng,Peng %A Xu,Youran %A Qian,Kaoliang %A Lu,Ming %A Hu,Jun %+ , Department of Orthopedics, First Affiliated Hospital of Nanjing Medical University, Guang Zhou Road 300, Nanjing, , China, 86 02568303196, junhu89@vip.sina.com %K case-based learning %K virtual reality %K pelvic fracture %K severe pelvic trauma %K hemodynamic instability %K clinical skill training %K VR %K pelvic trauma %K medical student %K pilot study %K orthopedic surgery %K theoretical teaching %K acceptability %D 2025 %7 17.1.2025 %9 Original Paper %J JMIR Med Educ %G English %X Background: Teaching severe pelvic trauma poses a significant challenge in orthopedic surgery education due to the necessity of both clinical reasoning and procedural operational skills for mastery. Traditional methods of instruction, including theoretical teaching and mannequin practice, face limitations due to the complexity, the unpredictability of treatment scenarios, the scarcity of typical cases, and the abstract nature of traditional teaching, all of which impede students’ knowledge acquisition. Objective: This study aims to introduce a novel experimental teaching methodology for severe pelvic trauma, integrating virtual reality (VR) technology as a potent adjunct to existing teaching practices. It evaluates the acceptability, perceived ease of use, and perceived usefulness among users and investigates its impact on knowledge, skills, and confidence in managing severe pelvic trauma before and after engaging with the software. Methods: A self-designed questionnaire was distributed to 40 students, and qualitative interviews were conducted with 10 teachers to assess the applicability and acceptability. A 1-group pretest-posttest design was used to evaluate learning outcomes across various domains, including diagnosis and treatment, preliminary diagnosis, disease treatment sequencing, emergency management of hemorrhagic shock, and external fixation of pelvic fractures. Results: A total of 40 students underwent training, with 95% (n=38) affirming that the software effectively simulated real-patient scenarios. All participants (n=40, 100%) reported that completing the simulation necessitated making the same decisions as doctors in real life and found the VR simulation interesting and useful. Teacher interviews revealed that 90% (9/10) recognized the VR simulation’s ability to replicate complex clinical cases, resulting in enhanced training effectiveness. Notably, there was a significant improvement in the overall scores for managing hemorrhagic shock (t39=37.6; 95% CI 43.6-48.6; P<.001) and performing external fixation of pelvic fractures (t39=24.1; 95% CI 53.4-63.3; P<.001) from pre- to postsimulation. Conclusions: The introduced case-based VR simulation of skill-training methodology positively influences medical students’ clinical reasoning, operative skills, and self-confidence. It offers an efficient strategy for conserving resources while providing quality education for both educators and learners. %M 39823600 %R 10.2196/59850 %U https://mededu.jmir.org/2025/1/e59850 %U https://doi.org/10.2196/59850 %U http://www.ncbi.nlm.nih.gov/pubmed/39823600 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63131 %T Evaluating Whether Nonimmersion Virtual Reality Simulation Training Improves Nursing Competency in Isolation Wards: Randomized Controlled Trial %A Zhang,Dandan %A Fu,MuLi %A Zhang,Jianzhong %A Li,Yuxuan %A Chen,Li %A Chen,Yong-Jun %A Zhong,Zhefeng %A Zhang,Yin-Ping %+ School of Nursing, Xi'an Jiaotong University Health Science Center, No.76, Yanta West Road, Xi'an, 7100061, China, 86 (29) 8265 7015, cathyzh@mail.xjtu.edu.cn %K virtual reality simulation %K isolation ward %K preparedness %K pandemic %K nurse %D 2025 %7 17.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: During infectious disease outbreaks such as the COVID-19 pandemic, nurses are crucial in patient care and public health safety; however, they face challenges such as inadequate training and high stress in isolation wards. Virtual reality (VR) technology offers innovative training solutions to enhance nurses’ clinical skills and preparedness. However, extensive studies on its effectiveness in isolation ward environments are still limited. Objective: This study aims to develop a nonimmersive VR (NIVR) simulation training program for isolation wards and further validate its feasibility and training effectiveness in aiding nurses in adapting to isolation ward settings. Methods: This study was a prospective, parallel, open-label, randomized controlled trial. A total of 90 nurses from 3 hospitals in China were randomly assigned to either the control or intervention group, with 45 (50%) individuals in each group. Both groups received training on isolation ward layout and nursing procedures. The control group underwent a 4-hour conventional training session consisting of 2 hours of face-to-face lectures and 2 hours of ward visits. The intervention group received a 4-hour NIVR simulation training session. Subsequently, both groups completed approximately 4 hours of emergency drills and assessments. Results: After the intervention, there were no significant differences in theoretical test or performance assessment scores between the 2 groups (t88=–0.30, P=.75; Cohen d=–0.06; z score=0.00, P>.99), using a 2-tailed t test. However, the intervention group completed 6 tasks faster than the control group (t88=5.10, P<.001; Cohen d=1.08), with an average reduction of about 3 minutes (control group: mean 43.91, SD 2.99 min; intervention group: mean 40.77, SD 2.85 min). Notably, they completed task 3 (patient reception inward) and task 6 (exiting the isolation area) significantly quicker (t88=3.22, P=.002; Cohen d=0.68; t88=3.03, P=.003; Cohen d=0.64, respectively), with no significant differences for the other tasks. Conclusions: This study highlights the potential of NIVR simulation training for nurses working in isolation wards. Although NIVR simulation training does not significantly surpass traditional methods in imparting theoretical knowledge, it does reduce task completion time for specific activities. Its capacity for safe, repetitive practice and realistic scenario simulation makes NIVR a valuable tool in medical education. Further research and optimization of VR simulation training programs are recommended to enhance nurses’ practical skills and pandemic preparedness. Trial Registration: Chinese Clinical Trial Registry ChiCTR240083155; https://www.chictr.org.cn/hvshowproject.html?id=250356&v=1.0 %M 39819587 %R 10.2196/63131 %U https://www.jmir.org/2025/1/e63131 %U https://doi.org/10.2196/63131 %U http://www.ncbi.nlm.nih.gov/pubmed/39819587 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e63448 %T A Mixed Reality–Based Telesupervised Ultrasound Education Platform on 5G Network Compared to Direct Supervision: Prospective Randomized Pilot Trial %A Kim,Minha %A Son,Meong Hi %A Moon,Suhyeon %A Cha,Won Chul %A Jo,Ik Joon %A Yoon,Hee %K ultrasonography %K telemedicine %K medical education %K distance learning %K fifth-generation network %K mixed reality %K ultrasound education %K hospital %K randomized pilot trial %K pilot study %K doctor %K telesupervision %K head-mounted display %K primary outcomes %K user experience %K self-confidence %K image quality %K educational intervention %K training experience %K South Korea %K telehealth %D 2025 %7 16.1.2025 %9 %J JMIR Serious Games %G English %X Background: Ultrasound education is transitioning from in-person training to remote methods using mixed reality (MR) and 5G networks. Previous studies are mainly experimental, lacking randomized controlled trials in direct training scenarios. Objective: This study aimed to compare an MR-based telesupervised ultrasound education platform on private 5G networks with traditional in-person training for novice doctors. Methods: Conducted at a tertiary academic hospital from November to December 2023, the prospective unblinded randomized controlled pilot study assigned doctors without prior abdominal ultrasound education experience to either the telesupervision group (TG; n=20) or direct supervision group (DG; n=20). Participants received a 15-minute video lecture, conducted ultrasound on a phantom, and had 18 images scored by 2 blinded experts. Additionally, the TG received 5 minutes of training on the basic operation of a head-mounted display. Communication between doctors in the TG and supervisors was facilitated through a head-mounted display, whereas those in the DG interacted directly with supervisors. Primary outcomes were image quality scores, while secondary outcomes included procedure time, number of supervisor interventions, user experience using National Aeronautics and Space Administration-Task Load Index (NASA-TLX), System Usability Scale (SUS), and self-confidence through pre- and postsurveys. Results: Image quality scores and procedure times showed no significant differences between the groups (TG: 66.8 [SD 10.3] vs DG: 66.8 [SD 10.4], P=.84; TG: 23.8 [SD 8.0] min vs DG: 24.0 [SD 8.1] min, P=.95, respectively). However, the TG engaged in more educational interventions (TG: 4.0 [SD 2.5] vs DG: 0.8 [SD 1.1], P<.001), reflecting a more interactive training environment. TG participants reported lower NASA-TLX scores for mental demand (43.8 [SD 24.8] vs 60.6 [SD 22.4], P=.03), effort (43.1 [SD 22.9] vs 67.9 [SD 17], P<.001), and frustration (26.9 [SD 20.3] vs 45.2 [SD 27.8], P=.02), indicating a reduced cognitive load compared to the DG. The mean SUS score was also higher in the TG (66.6 [SD 9.1] vs 60.2 [SD 10.4], P=.046), suggesting better usability. Both groups showed significant improvements in confidence, with the TG showing notably greater improvement in abdominal ultrasound proficiency (pre-education TG: 1.6 [SD 0.9] vs DG: 1.7 [SD 0.9], P=.73; post-education TG: 3.8 [SD 0.9] vs DG: 2.8 [SD 1.0], P=.006). Conclusions: Although no significant differences in image quality scores were observed between groups, considerable differences in positive educational interactions, workload, and usability were evident. These findings emphasize the platform’s potential to enhance the ultrasound training experience, suggesting more interactive and efficient learning. Trial Registration: ClinicalTrials.gov NCT06171828; https://clinicaltrials.gov/study/NCT06171828 %R 10.2196/63448 %U https://games.jmir.org/2025/1/e63448 %U https://doi.org/10.2196/63448 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e59435 %T Application of Large Language Models in Medical Training Evaluation—Using ChatGPT as a Standardized Patient: Multimetric Assessment %A Wang,Chenxu %A Li,Shuhan %A Lin,Nuoxi %A Zhang,Xinyu %A Han,Ying %A Wang,Xiandi %A Liu,Di %A Tan,Xiaomei %A Pu,Dan %A Li,Kang %A Qian,Guangwu %A Yin,Rong %+ West China Biomedical Big Data Center, West China Hospital, Sichuan University, No.37, Guoxue Lane, Wuhou District, Chengdu, 610041, China, 86 02881739902, likang@wchscu.cn %K ChatGPT %K artificial intelligence %K standardized patient %K health care %K prompt engineering %K accuracy %K large language models %K performance evaluation %K medical training %K inflammatory bowel disease %D 2025 %7 1.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: With the increasing interest in the application of large language models (LLMs) in the medical field, the feasibility of its potential use as a standardized patient in medical assessment is rarely evaluated. Specifically, we delved into the potential of using ChatGPT, a representative LLM, in transforming medical education by serving as a cost-effective alternative to standardized patients, specifically for history-taking tasks. Objective: The study aims to explore ChatGPT’s viability and performance as a standardized patient, using prompt engineering to refine its accuracy and use in medical assessments. Methods: A 2-phase experiment was conducted. The first phase assessed feasibility by simulating conversations about inflammatory bowel disease (IBD) across 3 quality groups (good, medium, and bad). Responses were categorized based on their relevance and accuracy. Each group consisted of 30 runs, with responses scored to determine whether they were related to the inquiries. For the second phase, we evaluated ChatGPT’s performance against specific criteria, focusing on its anthropomorphism, clinical accuracy, and adaptability. Adjustments were made to prompts based on ChatGPT’s response shortcomings, with a comparative analysis of ChatGPT’s performance between original and revised prompts. A total of 300 runs were conducted and compared against standard reference scores. Finally, the generalizability of the revised prompt was tested using other scripts for another 60 runs, together with the exploration of the impact of the used language on the performance of the chatbot. Results: The feasibility test confirmed ChatGPT’s ability to simulate a standardized patient effectively, differentiating among poor, medium, and good medical inquiries with varying degrees of accuracy. Score differences between the poor (74.7, SD 5.44) and medium (82.67, SD 5.30) inquiry groups (P<.001), between the poor and good (85, SD 3.27) inquiry groups (P<.001) were significant at a significance level (α) of .05, while the score differences between the medium and good inquiry groups were not statistically significant (P=.16). The revised prompt significantly improved ChatGPT’s realism, clinical accuracy, and adaptability, leading to a marked reduction in scoring discrepancies. The score accuracy of ChatGPT improved 4.926 times compared to unrevised prompts. The score difference percentage drops from 29.83% to 6.06%, with a drop in SD from 0.55 to 0.068. The performance of the chatbot on a separate script is acceptable with an average score difference percentage of 3.21%. Moreover, the performance differences between test groups using various language combinations were found to be insignificant. Conclusions: ChatGPT, as a representative LLM, is a viable tool for simulating standardized patients in medical assessments, with the potential to enhance medical training. By incorporating proper prompts, ChatGPT’s scoring accuracy and response realism significantly improved, approaching the feasibility of actual clinical use. Also, the influence of the adopted language is nonsignificant on the outcome of the chatbot. %M 39742453 %R 10.2196/59435 %U https://www.jmir.org/2025/1/e59435 %U https://doi.org/10.2196/59435 %U http://www.ncbi.nlm.nih.gov/pubmed/39742453 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e57655 %T Enhancing Mixed Reality Simulation Training Technology With Real-Time Performance Visualization: Mixed Methods Study With Medical First Responders %A Zechner,Olivia %A Schrom-Feiertag,Helmut %A Wespi,Rafael %A Pretolesi,Daniele %A Nguyen,Quynh %A Tscheligi,Manfred %K mixed reality %K immersive technologies %K simulation training %K simulation %K paramedic %K medical first responders %K human performance %K stress %K stress monitoring %K human-centered design %D 2024 %7 24.12.2024 %9 %J JMIR XR Spatial Comput %G English %X Background: Mixed reality (MR) simulation training is emerging in paramedical education as a way to practice responding to stress-intensive scenarios like mass casualty incidents in a safe and controlled environment. Current training platforms, however, lack real-time stress and human performance monitoring tools. Objective: The study aims to enhance MR training for medical first responders through real-time evaluation of performance and stress levels, leveraging biosignal monitoring and advanced analytics to allow instructors to tailor feedback and maintain optimal challenge and safety levels. Methods: The study includes a structured, multiphase approach including initial requirement gathering (structured interviews and cocreation workshops), an online design survey, iterative prototype development, and a field trial (including training observations and interviews). Data were collected from 5 end user consortium members across Europe. Quantitative data from checklists were analyzed using frequencies and percentages to understand feature usage and event occurrences. Qualitative data from semistructured interviews and cocreation workshops were transcribed, coded, and subjected to thematic analysis to identify patterns and insights into the usability and effectiveness of the enhanced features in the MR training. Results: The study identified a number of requirements that medical first responders have for an MR training system, including requirements not included in currently available solutions. A total of 80 performance metrics were initially identified and refined to a set of 54 metrics, which were categorized into key performance indicator groups such as scene safety, triage performance, and communication. Requirements for smart wearables to monitor stress levels are provided and highlight the importance of a user-centered design process to provide users with effective tools that fit their needs. Stress visualization preferences are described in the form of a dashboard as well as in virtual environments surrounding the avatar. Using an iterative design process and user feedback, a training system was developed, integrating real-time performance tracking and stress monitoring. The field trial provided insights into the practical use of these features during a real training exercise, showed interaction preferences between trainer and trainees, and highlighted further improvement opportunities. Conclusions: This research enhances MR training for paramedics by integrating real-time performance metrics and stress indicators based on a human-centered design approach that aligns with end user needs, thereby laying the foundation for developing more effective and immersive training solutions for high-stress professions. %R 10.2196/57655 %U https://xr.jmir.org/2024/1/e57655 %U https://doi.org/10.2196/57655 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e59720 %T Influence of Training With Corrective Feedback Devices on Cardiopulmonary Resuscitation Skills Acquisition and Retention: Systematic Review and Meta-Analysis %A Nicolau,Abel %A Jorge,Inês %A Vieira-Marques,Pedro %A Sa-Couto,Carla %+ RISE-Health, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, 351 220426836, anicolau@med.up.pt %K cardiopulmonary resuscitation %K CPR quality %K resuscitation training %K corrective feedback devices %K skills acquisition %K skills retention %K systematic review %K evidence-based research %K meta-analysis %K feedback devices %K PRISMA %D 2024 %7 19.12.2024 %9 Review %J JMIR Med Educ %G English %X Background: Several studies related to the use of corrective feedback devices in cardiopulmonary resuscitation training, with different populations, training methodologies, and equipment, present distinct results regarding the influence of this technology. Objective: This systematic review and meta-analysis aimed to examine the impact of corrective feedback devices in cardiopulmonary resuscitation skills acquisition and retention for laypeople and health care professionals. Training duration was also studied. Methods: The search was conducted in PubMed, Web of Science, and Scopus from January 2015 to December 2023. Eligible randomized controlled trials compared technology-based training incorporating corrective feedback with standard training. Outcomes of interest were the quality of chest compression–related components. The risk of bias was assessed using the Cochrane tool. A meta-analysis was used to explore the heterogeneity of the selected studies. Results: In total, 20 studies were included. Overall, it was reported that corrective feedback devices used during training had a positive impact on both skills acquisition and retention. Medium to high heterogeneity was observed. Conclusions: This systematic review and meta-analysis suggest that corrective feedback devices enhance skills acquisition and retention over time. Considering the medium to high heterogeneity observed, these findings should be interpreted with caution. More standardized, high-quality studies are needed. Trial Registration: PROSPERO CRD42021240953; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=240953 %M 39699935 %R 10.2196/59720 %U https://mededu.jmir.org/2024/1/e59720 %U https://doi.org/10.2196/59720 %U http://www.ncbi.nlm.nih.gov/pubmed/39699935 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e52068 %T Evaluation of a Computer-Based Morphological Analysis Method for Free-Text Responses in the General Medicine In-Training Examination: Algorithm Validation Study %A Yokokawa,Daiki %A Shikino,Kiyoshi %A Nishizaki,Yuji %A Fukui,Sho %A Tokuda,Yasuharu %K General Medicine In-Training Examination %K free-text response %K morphological analysis %K Situation, Background, Assessment, and Recommendation %K video-based question %D 2024 %7 5.12.2024 %9 %J JMIR Med Educ %G English %X Background: The General Medicine In-Training Examination (GM-ITE) tests clinical knowledge in a 2-year postgraduate residency program in Japan. In the academic year 2021, as a domain of medical safety, the GM-ITE included questions regarding the diagnosis from medical history and physical findings through video viewing and the skills in presenting a case. Examinees watched a video or audio recording of a patient examination and provided free-text responses. However, the human cost of scoring free-text answers may limit the implementation of GM-ITE. A simple morphological analysis and word-matching model, thus, can be used to score free-text responses. Objective: This study aimed to compare human versus computer scoring of free-text responses and qualitatively evaluate the discrepancies between human- and machine-generated scores to assess the efficacy of machine scoring. Methods: After obtaining consent for participation in the study, the authors used text data from residents who voluntarily answered the GM-ITE patient reproduction video-based questions involving simulated patients. The GM-ITE used video-based questions to simulate a patient’s consultation in the emergency room with a diagnosis of pulmonary embolism following a fracture. Residents provided statements for the case presentation. We obtained human-generated scores by collating the results of 2 independent scorers and machine-generated scores by converting the free-text responses into a word sequence through segmentation and morphological analysis and matching them with a prepared list of correct answers in 2022. Results: Of the 104 responses collected—63 for postgraduate year 1 and 41 for postgraduate year 2—39 cases remained for final analysis after excluding invalid responses. The authors found discrepancies between human and machine scoring in 14 questions (7.2%); some were due to shortcomings in machine scoring that could be resolved by maintaining a list of correct words and dictionaries, whereas others were due to human error. Conclusions: Machine scoring is comparable to human scoring. It requires a simple program and calibration but can potentially reduce the cost of scoring free-text responses. %R 10.2196/52068 %U https://mededu.jmir.org/2024/1/e52068 %U https://doi.org/10.2196/52068 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e56195 %T Effectiveness of Virtual Simulations Versus Mannequins and Real Persons in Medical and Nursing Education: Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials %A Jiang,Nan %A Zhang,Yuelun %A Liang,Siyu %A Lyu,Xiaohong %A Chen,Shi %A Huang,Xiaoming %A Pan,Hui %+ Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Translation Medicine Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan,Wangfujing, Dongcheng District, Beijing, 100730, China, 86 13683136205, cspumch@163.com %K artificial intelligence %K clinical virtual simulation %K medical education %K meta-analysis %K nursing education %K virtual patient %K virtual reality %D 2024 %7 5.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual simulation (VS) is a developing education approach with the recreation of reality using digital technology. The teaching effectiveness of VSs compared to mannequins and real persons (RPs) has never been investigated in medical and nursing education. Objective: This study aims to compare VSs and mannequins or RPs in improving the following clinical competencies: knowledge, procedural skills, clinical reasoning, and communication skills. Methods: Following Cochrane methodology, a meta-analysis was conducted on the effectiveness of VSs in pre- and postregistration medical or nursing participants. The Cochrane Library, PubMed, Embase, and Educational Resource Information Centre databases were searched to identify English-written randomized controlled trials up to August 2024. Two authors independently selected studies, extracted data, and assessed the risk of bias. All pooled estimates were based on random-effects models and assessed by trial sequential analyses. Leave-one-out, subgroup, and univariate meta-regression analyses were performed to explore sources of heterogeneity. Results: A total of 27 studies with 1480 participants were included. Overall, there were no significant differences between VSs and mannequins or RPs in improving knowledge (standard mean difference [SMD]=0.08; 95% CI –0.30 to 0.47; I2=67%; P=.002), procedural skills (SMD=–0.12; 95% CI –0.47 to 0.23; I2=75%; P<.001), clinical reasoning (SMD=0.29; 95% CI –0.26 to 0.85; I2=88%; P<.001), and communication skills (SMD=–0.02; 95% CI: –0.62 to 0.58; I2=86%; P<.001). Trial sequential analysis for clinical reasoning indicated an insufficient sample size for a definitive judgment. For procedural skills, subgroup analyses showed that VSs were less effective among nursing participants (SMD=–0.55; 95% CI –1.07 to –0.03; I2=69%; P=.04). Univariate meta-regression detected a positive effect of publication year (β=.09; P=.02) on communication skill scores. Conclusions: Given favorable cost-utility plus high flexibility regarding time and space, VSs are viable alternatives to traditional face-to-face learning modalities. The comparative effectiveness of VSs deserves to be followed up with the emergence of new technology. In addition, further investigation of VSs with different design features will provide novel insights to drive education reform. Trial Registration: PROSPERO CRD42023466622; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=466622 %M 39636688 %R 10.2196/56195 %U https://www.jmir.org/2024/1/e56195 %U https://doi.org/10.2196/56195 %U http://www.ncbi.nlm.nih.gov/pubmed/39636688 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59439 %T Mitigating Cognitive Biases in Clinical Decision-Making Through Multi-Agent Conversations Using Large Language Models: Simulation Study %A Ke,Yuhe %A Yang,Rui %A Lie,Sui An %A Lim,Taylor Xin Yi %A Ning,Yilin %A Li,Irene %A Abdullah,Hairil Rizal %A Ting,Daniel Shu Wei %A Liu,Nan %+ Centre for Quantitative Medicine, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore, 65 66016503, liu.nan@duke-nus.edu.sg %K clinical decision-making %K cognitive bias %K generative artificial intelligence %K large language model %K multi-agent %D 2024 %7 19.11.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive biases in clinical decision-making significantly contribute to errors in diagnosis and suboptimal patient outcomes. Addressing these biases presents a formidable challenge in the medical field. Objective: This study aimed to explore the role of large language models (LLMs) in mitigating these biases through the use of the multi-agent framework. We simulate the clinical decision-making processes through multi-agent conversation and evaluate its efficacy in improving diagnostic accuracy compared with humans. Methods: A total of 16 published and unpublished case reports where cognitive biases have resulted in misdiagnoses were identified from the literature. In the multi-agent framework, we leveraged GPT-4 (OpenAI) to facilitate interactions among different simulated agents to replicate clinical team dynamics. Each agent was assigned a distinct role: (1) making the final diagnosis after considering the discussions, (2) acting as a devil’s advocate to correct confirmation and anchoring biases, (3) serving as a field expert in the required medical subspecialty, (4) facilitating discussions to mitigate premature closure bias, and (5) recording and summarizing findings. We tested varying combinations of these agents within the framework to determine which configuration yielded the highest rate of correct final diagnoses. Each scenario was repeated 5 times for consistency. The accuracy of the initial diagnoses and the final differential diagnoses were evaluated, and comparisons with human-generated answers were made using the Fisher exact test. Results: A total of 240 responses were evaluated (3 different multi-agent frameworks). The initial diagnosis had an accuracy of 0% (0/80). However, following multi-agent discussions, the accuracy for the top 2 differential diagnoses increased to 76% (61/80) for the best-performing multi-agent framework (Framework 4-C). This was significantly higher compared with the accuracy achieved by human evaluators (odds ratio 3.49; P=.002). Conclusions: The multi-agent framework demonstrated an ability to re-evaluate and correct misconceptions, even in scenarios with misleading initial investigations. In addition, the LLM-driven, multi-agent conversation framework shows promise in enhancing diagnostic accuracy in diagnostically challenging medical scenarios. %M 39561363 %R 10.2196/59439 %U https://www.jmir.org/2024/1/e59439 %U https://doi.org/10.2196/59439 %U http://www.ncbi.nlm.nih.gov/pubmed/39561363 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e56844 %T Virtual Reality Simulation in Undergraduate Health Care Education Programs: Usability Study %A Mørk,Gry %A Bonsaksen,Tore %A Larsen,Ole Sønnik %A Kunnikoff,Hans Martin %A Lie,Silje Stangeland %+ Department of Health, Faculty of Health Sciences, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, 47 47234324, gry.mork@vid.no %K 360° videos %K health professions education %K virtual reality %K usability study %K undergraduates %K university %K students %K simulation %D 2024 %7 19.11.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality (VR) is increasingly being used in higher education for clinical skills training and role-playing among health care students. Using 360° videos in VR headsets, followed by peer debrief and group discussions, may strengthen students’ social and emotional learning. Objective: This study aimed to explore student-perceived usability of VR simulation in three health care education programs in Norway. Methods: Students from one university participated in a VR simulation program. Of these, students in social education (n=74), nursing (n=45), and occupational therapy (n=27) completed a questionnaire asking about their perceptions of the usability of the VR simulation and the related learning activities. Differences between groups of students were examined with Pearson chi-square tests and with 1-way ANOVA. Qualitative content analysis was used to analyze data from open-ended questions. Results: The nursing students were most satisfied with the usability of the VR simulation, while the occupational therapy students were least satisfied. The nursing students had more often prior experience from using VR technology (60%), while occupational therapy students less often had prior experience (37%). Nevertheless, high mean scores indicated that the students experienced the VR simulation and the related learning activities as very useful. The results also showed that by using realistic scenarios in VR simulation, health care students can be prepared for complex clinical situations in a safe environment. Also, group debriefing sessions are a vital part of the learning process that enhance active involvement with peers. Conclusions: VR simulation has promise and potential as a pedagogical tool in health care education, especially for training soft skills relevant for clinical practice, such as communication, decision-making, time management, and critical thinking. %M 39560982 %R 10.2196/56844 %U https://mededu.jmir.org/2024/1/e56844 %U https://doi.org/10.2196/56844 %U http://www.ncbi.nlm.nih.gov/pubmed/39560982 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e64476 %T The Effect of Virtual Laboratories on the Academic Achievement of Undergraduate Chemistry Students: Quasi-Experimental Study %A Bazie,Hiwot %A Lemma,Bekele %A Workneh,Anteneh %A Estifanos,Ashebir %+ Department of Chemistry, College of Natural and Computational Science, Hawassa University, Hawassa University Main Campus, Hawassa, 1530, Ethiopia, 251 918778422, baziebe@gmail.com %K virtual laboratory %K practical chemistry %K student achievement %K undergraduate student %K Dilla University %K simulation %K chemistry education %D 2024 %7 15.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Experimentation is crucial in chemistry education as it links practical experience with theoretical concepts. However, practical chemistry courses typically rely on real laboratory experiments and often face challenges such as limited resources, equipment shortages, and logistical constraints in university settings. To address these challenges, computer-based laboratories have been introduced as a potential solution, offering electronic simulations that replicate real laboratory experiences. Objective: This study examines the effect of virtual laboratories on the academic achievement of undergraduate chemistry students and evaluates their potential as a viable alternative or complement to traditional laboratory-based instruction. Methods: A quasi-experimental design was implemented to examine the cause-and-effect relationship between instructional methods and student outcomes. The study involved 60 fourth-year BSc chemistry students from Dilla University, divided into 3 groups: a real laboratory group (n=20), which performed real laboratory experiments; a virtual group (n=20), which used virtual laboratory simulations; and a lecture group (n=20), which received lecture-based instruction. Quantitative data were collected through tests administered before and after the intervention to assess academic performance. The data analysis used descriptive and inferential statistics, such as means and SDs, 1-way ANOVA, the Tukey honestly significant difference test, and independent-sample t tests (2-tailed), with a P value of .05 set for determining statistical significance. Results: Before the intervention, the results indicated no significant differences in academic achievement among the 3 groups (P=.99). However, after the intervention, notable differences were observed in student performance across the methods. The real laboratory group had the highest mean posttest score (mean 62.6, SD 10.7), followed by the virtual laboratory group (mean 55.5, SD 6.8) and the lecture-only group, which had the lowest mean score (mean 43.7, SD 11.5). ANOVA results confirmed significant differences between the groups (F2,57=18.429; P<.001). The Tukey post hoc test further revealed that the real laboratory group significantly outperformed the lecture-only group (mean difference 18.88; P<.001), while the virtual laboratory group also performed significantly better than the lecture-only group (mean difference 11.7; P=.001). However, no statistically significant difference was found between the real laboratory and virtual laboratory groups (mean difference 7.12; P=.07). In addition, gender did not significantly influence performance in the virtual laboratory group (P=.21), with no substantial difference in posttest scores between male and female students. Conclusions: These findings suggest that computer-based laboratories are a viable and effective alternative when real laboratories are unavailable, enhancing learning outcomes when compared with traditional lecture-based methods. Therefore, universities should consider integrating computer-based laboratories into their practical chemistry curricula to provide students with interactive and engaging learning experiences, especially when physical laboratories are inaccessible. %M 39546770 %R 10.2196/64476 %U https://formative.jmir.org/2024/1/e64476 %U https://doi.org/10.2196/64476 %U http://www.ncbi.nlm.nih.gov/pubmed/39546770 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e47141 %T Using Games to Simulate Medication Adherence and Nonadherence: Laboratory Experiment in Gamified Behavioral Simulation %A Taj,Umar %A Grimani,Aikaterini %A Read,Daniel %A Vlaev,Ivo %K behavior change %K experimental modeling %K gamification %K medication adherence %K antibiotics %K games %K medication %K testing behavior %K clinical outcome %K simulate %K diagnosis %K devices %K symptoms %K tool %D 2024 %7 24.9.2024 %9 %J JMIR Serious Games %G English %X Background: Medical nonadherence is a significant problem associated with worse clinical outcomes, higher downstream rehospitalization rates, and a higher use of resources. To improve medication adherence, it is vital for researchers and practitioners to have a solid theoretical understanding of what interventions are likely to work. To achieve this understanding, we propose that researchers should focus on creating small-scale laboratory analogs to the larger real-world setting and determine what interventions, such as nudges or incentives, work to change behavior in the laboratory. To do this, we took inspiration from the literature on serious games and gamification and experimental economics. We call our approach “gamified behavioral simulation.” In this paper, we modeled everyday life as the state of being engaged in a simple but addictive game, illness as being interruptions to the functionality of that game, treatment as being a series of actions that can be taken to prevent or mitigate those interruptions, and adherence as sticking to a prescribed rule for the application of those actions. Objective: This study carries out a behavioral diagnosis of the medication adherence problem through a theoretically informed framework and then develops the gamified behavioral modeling approach to simulate medication nonadherence. Methods: A laboratory experiment was conducted using a modified popular and addictive open-source video game called “2048,” which created an abstract model for the medication adherence behavior observed in real life. In total, 509 participants were assigned to the control and 4 intervention groups (“incentive” group, “reminder” group, “commitment device” group, and “elongated duration for symptoms” group). Results: The results of the modeling experiment showed that having theoretically informed interventions can increase the likelihood for them to be successful. In particular, there is evidence that the use of reminders improves the medication adherence rates for patients, and the same result was found in the modeling experiment, as they improved adherence significantly by 23% (95% CI −33.97% to −11.72%; P<.001). However, providing an incentive did not improve the adherence rate. We also tested the use of commitment devices, which, in line with real-world evidence, did not improve adherence rates. The fourth treatment tested elongated duration for symptoms, which attempted to show the power of modeling experiments where we test a what-if scenario that is extremely difficult to test in a real setting. The results indicated that if symptoms last longer, people did not adhere more to their medication regimen. Conclusions: Gamified behavioral simulation is a useful tool to explain real health behaviors and help in identifying which interventions are most likely to work in a randomized trial. %R 10.2196/47141 %U https://games.jmir.org/2024/1/e47141 %U https://doi.org/10.2196/47141 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e58753 %T Enhancing Medical Interview Skills Through AI-Simulated Patient Interactions: Nonrandomized Controlled Trial %A Yamamoto,Akira %A Koda,Masahide %A Ogawa,Hiroko %A Miyoshi,Tomoko %A Maeda,Yoshinobu %A Otsuka,Fumio %A Ino,Hideo %+ Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan, 81 86 235 7342, ymtakira@gmail.com %K medical interview %K generative pretrained transformer %K large language model %K simulation-based learning %K OSCE %K artificial intelligence %K medical education %K simulated patients %K nonrandomized controlled trial %D 2024 %7 23.9.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Medical interviewing is a critical skill in clinical practice, yet opportunities for practical training are limited in Japanese medical schools, necessitating urgent measures. Given advancements in artificial intelligence (AI) technology, its application in the medical field is expanding. However, reports on its application in medical interviews in medical education are scarce. Objective: This study aimed to investigate whether medical students’ interview skills could be improved by engaging with AI-simulated patients using large language models, including the provision of feedback. Methods: This nonrandomized controlled trial was conducted with fourth-year medical students in Japan. A simulation program using large language models was provided to 35 students in the intervention group in 2023, while 110 students from 2022 who did not participate in the intervention were selected as the control group. The primary outcome was the score on the Pre-Clinical Clerkship Objective Structured Clinical Examination (pre-CC OSCE), a national standardized clinical skills examination, in medical interviewing. Secondary outcomes included surveys such as the Simulation-Based Training Quality Assurance Tool (SBT-QA10), administered at the start and end of the study. Results: The AI intervention group showed significantly higher scores on medical interviews than the control group (AI group vs control group: mean 28.1, SD 1.6 vs 27.1, SD 2.2; P=.01). There was a trend of inverse correlation between the SBT-QA10 and pre-CC OSCE scores (regression coefficient –2.0 to –2.1). No significant safety concerns were observed. Conclusions: Education through medical interviews using AI-simulated patients has demonstrated safety and a certain level of educational effectiveness. However, at present, the educational effects of this platform on nonverbal communication skills are limited, suggesting that it should be used as a supplementary tool to traditional simulation education. %M 39312284 %R 10.2196/58753 %U https://mededu.jmir.org/2024/1/e58753 %U https://doi.org/10.2196/58753 %U http://www.ncbi.nlm.nih.gov/pubmed/39312284 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e56436 %T Socioemotional Skills in the Teaching-Learning Process Mediated by Medium- and High-Fidelity Clinical Simulation in Nursing Students: Protocol for a Scoping Review %A Contreras-Ramos,Luz Mery %A Laguado Jaimes,Elveny %A Jaimes Carvajal,Nelly Esperanza %A Pico Ferreira,Marleny %A Villamizar-Osorio,Magda Liliana %+ Faculty of Nursing, Universidad Cooperativa de Colombia, Carrera 33 # 30A -05, Bucaramanga, 680001, Colombia, 57 607 685 45 00 ext 7060, luz.contrerasr@campusucc.edu.co %K social skills %K nursing students %K high-fidelity simulation training %D 2024 %7 19.8.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: In nursing education, contact with real scenarios implies the design of favorable experiences to develop prioritization, reasoning, critical thinking, and management skills that support future practice. In the context of the teaching-learning process, simulation emerges as a support strategy, but its use and management require the knowledge and appropriation of teachers. Clinical simulation during education promotes growth in technical skills and aptitudes such as critical thinking, emotional management, organization, delegation, and teamwork. The culmination positively impacts the student, reflecting on their confidence, security, and adaptability to unexpected or unknown situations and risks. Objective: The aim of this scoping review is to determine the socioemotional skills described during the teaching-learning process mediated by medium- and high-fidelity clinical simulation in nursing students. Methods: The main concepts and limits of the research area will be determined according to the 5 phases of a scoping review proposed by Arksey and O’Malley. Research articles and postgraduate theses published between 2010 and 2023 in English and Spanish will be considered. Dissertation-type documents, book chapters, editorials, abstracts, and articles focused on clinical simulation among nursing professionals will be excluded. The articles will be retrieved from databases available at the Universidad Cooperativa de Colombia, along with CINAHL, Scielo, and PubMed. The search strategy will be based on the Population-Concept-Context framework. Article selection will be carried out by 2 independent evaluators who will review titles and abstracts in stage 1 and the full text in stage 2. A database of retrieved articles will be built with the variables of interest. A qualitative thematic analysis will be conducted by 5 independent reviewers to provide an overview of the literature, focusing on identifying similarities and contrasts between studies and contributions related to the aspects of social skills described in nursing students. Results: The investigation has not yet started. The findings aim to focus on variables within the academic environment that, when correlated with the clinical simulation experience, may determine student learning. The working hypothesis is that students who experience greater satisfaction or possess better communication skills also demonstrate superior performance during high-fidelity simulation activities. The most relevant results will be contrasted considering the stated objective and knowledge gaps. Key aspects will also be compared with other reviews addressing related topics such as communication, self-efficacy, and self-confidence. Skills described by other authors that were not considered in the initial literature review will also be mentioned. Conclusions: Educational institutions are responsible for including learning experiences in controlled environments such as medium- and high-fidelity simulation to ensure the acquisition of technical capabilities and additional socioemotional skills. Recognizing and managing emotions is necessary to provide adequate care for users of health care services and for the increased effectiveness of professionals. Trial Registration: Open Science Framework p4ays; https://osf.io/p4ays International Registered Report Identifier (IRRID): PRR1-10.2196/56436 %M 39158944 %R 10.2196/56436 %U https://www.researchprotocols.org/2024/1/e56436 %U https://doi.org/10.2196/56436 %U http://www.ncbi.nlm.nih.gov/pubmed/39158944 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e53106 %T Multidisciplinary Design–Based Multimodal Virtual Reality Simulation in Nursing Education: Mixed Methods Study %A Yeo,Ji-Young %A Nam,Hyeongil %A Park,Jong-Il %A Han,Soo-Yeon %+ Department of Nursing, Bucheon University, sosa-ro 56, Bucheon, 14774, Republic of Korea, 82 326108312, sooyeonhan@bc.ac.kr %K multidisciplinary %K multimodal %K nursing %K simulation %K virtual reality %K VR %K education %K allied health %K educational %K simulations %K pediatric %K pediatrics %K paediatric %K paediatrics %K feasibility %K nurse %K nurses %K qualitative %K interview %K interviews %K development %K develop %K teaching %K educator %K educators %K user test %K user testing %K module %K modules %K usability %K satisfaction %D 2024 %7 26.7.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: The COVID-19 pandemic underscored the necessity for innovative educational methods in nursing. Our study takes a unique approach using a multidisciplinary simulation design, which offers a systematic and comprehensive strategy for developing virtual reality (VR) simulations in nursing education. Objective: The aim of this study is to develop VR simulation content for a pediatric nursing module based on a multidisciplinary simulation design and to evaluate its feasibility for nursing education. Methods: This study used a 1-group, posttest-only design. VR content for pediatric nursing practice was developed by integrating the technological characteristics of a multimodal VR system with the learning elements of traditional nursing simulation, combining various disciplines, including education, engineering, and nursing. A user test was conducted with 12 nursing graduates (preservice nurses) followed by post hoc surveys (assessing presence, VR systems, VR sickness, and simulation satisfaction) and in-depth, one-on-one interviews. Results: User tests showed mean scores of 4.01 (SD 1.43) for presence, 4.91 (SD 0.81) for the VR system, 0.64 (SD 0.35) for VR sickness, and 5.00 (SD 1.00) for simulation satisfaction. In-depth interviews revealed that the main strengths of the immersive VR simulation for pediatric pneumonia nursing were effective visualization and direct experience through hands-on manipulation; the drawback was keyword-based voice interaction. To improve VR simulation quality, participants suggested increasing the number of nursing techniques and refining them in more detail. Conclusions: This VR simulation content for a pediatric nursing practice using a multidisciplinary educational design model was confirmed to have positive educational potential. Further research is needed to confirm the specific learning effects of immersive nursing content based on multidisciplinary design models. %M 39058550 %R 10.2196/53106 %U https://mededu.jmir.org/2024/1/e53106 %U https://doi.org/10.2196/53106 %U http://www.ncbi.nlm.nih.gov/pubmed/39058550 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53165 %T Pressure Ulcer Management Virtual Reality Simulation (PU-VRSim) for Novice Nurses: Mixed Methods Study %A Jung,Soo Youn %A Moon,Kyoung Ja %+ College of Nursing, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea, 82 53 258 7663, kjmoon2150@gmail.com %K virtual reality %K nursing %K simulation %K virtual training %K pressure ulcer %K simulation training %K nurse %K clinician %K health care worker %K ulcer %K hospital %K health care center %K PU-VRSim %K mixed methods study %K health professional %K medical education %K training %K games %K gamification %K learning %K decubitus ulcer %D 2024 %7 24.6.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Pressure ulcers (PUs) are a common and serious complication in patients who are immobile in health care settings. Nurses play a fundamental role in the prevention of PUs; however, novice nurses lack experience in clinical situations. Virtual reality (VR) is highly conducive to clinical- and procedure-focused training because it facilitates simulations. Objective: We aimed to explore the feasibility of a novel PU management VR simulation (PU-VRSim) program using a head-mounted display for novice nurses and to investigate how different types of learning materials (ie, VR or a video-based lecture) impact learning outcomes and experiences. Methods: PU-VRSim was created in the Unity 3D platform. This mixed methods pilot quasi-experimental study included 35 novice nurses categorized into the experimental (n=18) and control (n=17) groups. The PU-VRSim program was applied using VR in the experimental group, whereas the control group received a video-based lecture. The PU knowledge test, critical thinking disposition measurement tool, and Korean version of the General Self-Efficacy Scale were assessed before and after the intervention in both groups. After the intervention, the experimental group was further assessed using the Clinical Judgment Rubric and interviewed to evaluate their experience with PU-VRSim. Results: The results compared before and after the intervention showed significant improvements in PU knowledge in both the experimental group (P=.001) and control group (P=.005). There were no significant differences in self-efficacy and critical thinking in either group. The experimental group scored a mean of 3.23 (SD 0.44) points (accomplished) on clinical judgment, assessed using a 4-point scale. The experimental group interviews revealed that the VR simulation was realistic and helpful for learning about PU management. Conclusions: The results revealed that PU-VRSim could improve novice nurses’ learning of PU management in realistic environments. Further studies using VR for clinical training are recommended for novice nurses. %M 38913417 %R 10.2196/53165 %U https://games.jmir.org/2024/1/e53165 %U https://doi.org/10.2196/53165 %U http://www.ncbi.nlm.nih.gov/pubmed/38913417 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e53167 %T Exploring the Distribution of 3D-Printed Simulator Designs Using Open-Source Databases to Facilitate Simulation-Based Learning Through a University and Nonprofit Collaboration: Protocol for a Scoping Review %A Sritharan,Mithusha %A Siraj,Samyah %A Brunton,Ginny %A Dubrowski,Adam %+ Faculty of Health Sciences, Ontario Tech University, 2000 Simcoe St N, Oshawa, ON, L1G 0C5, Canada, 1 905 721 8668, samyah.siraj@ontariotechu.net %K simulation %K three-dimensional printing %K health professions education %K database %K simulator %K simulator design %K health care provider training %K simulation-based education %K simulation technology %K open-source %K databases %K simulation-based learning %K e-Learning %K scoping review %K technology %K 3D printed simulators %K design %K 3D printing %K 3D %K health care training %K university-based %K research centers %K gaps %D 2024 %7 27.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Advancements in technology have enhanced education, training, and application in health care. However, limitations are present surrounding the accessibility and use of simulation technology (eg, simulators) for health profession education. Improving the accessibility of technology developed in university-based research centers by nonprofit organizations (NPOs; eg, hospitals) has the potential to benefit the health of populations worldwide. One example of such technology is 3D-printed simulators. Objective: This scoping review aims to identify how the use of open-source databases for the distribution of simulator designs used for 3D printing can promote credible solutions for health care training while minimizing the risks of commercialization of designs for profit. Methods: This scoping review will follow the Arksey and O’Malley methodological framework and the Joanna Briggs Institute guidance for scoping reviews. Ovid MEDLINE, CINAHL, Web of Science, and PsycINFO will be searched with an applied time frame of 2012 to 2022. Additionally, gray literature will be searched along with reference list searching. Papers that explore the use of open-source databases in academic settings and the health care sector for the distribution of simulator designs will be included. A 2-step screening process will be administered to titles and abstracts, then full texts, to establish paper eligibility. Screening and data extraction of the papers will be completed by 2 reviewers (MS and SS) for quality assurance. The scoping review will report information on the facilitation of distributing 3D-printed simulator designs through open-source databases. Results: The results of this review will identify gaps in forming partnerships with NPOs and university-based research centers to share simulator designs. The scoping review will be initiated in December 2024. Conclusions: The information collected will be relevant and useful for stakeholders such as health care providers, researchers, and NPOs for the purpose of overcoming the gaps in research regarding the use and distribution of simulation technology. The scoping review has not been conducted yet. Therefore, there are currently no findings to report on. International Registered Report Identifier (IRRID): PRR1-10.2196/53167 %M 38801764 %R 10.2196/53167 %U https://www.researchprotocols.org/2024/1/e53167 %U https://doi.org/10.2196/53167 %U http://www.ncbi.nlm.nih.gov/pubmed/38801764 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e38170 %T Comparing Contact Tracing Through Bluetooth and GPS Surveillance Data: Simulation-Driven Approach %A Qian,Weicheng %A Cooke,Aranock %A Stanley,Kevin Gordon %A Osgood,Nathaniel David %+ Department of Computer Science, University of Saskatchewan, 110 Science Place, Saskatoon, SK, S7N 5C9, Canada, 1 3069661947, weicheng.qian@usask.ca %K smartphone-based sensing %K proximity contact data %K transmission models %K agent-based simulation %K health informatics %K mobile phone %D 2024 %7 17.4.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Accurate and responsive epidemiological simulations of epidemic outbreaks inform decision-making to mitigate the impact of pandemics. These simulations must be grounded in quantities derived from measurements, among which the parameters associated with contacts between individuals are notoriously difficult to estimate. Digital contact tracing data, such as those provided by Bluetooth beaconing or GPS colocating, can provide more precise measures of contact than traditional methods based on direct observation or self-reporting. Both measurement modalities have shortcomings and are prone to false positives or negatives, as unmeasured environmental influences bias the data. Objective: We aim to compare GPS colocated versus Bluetooth beacon–derived proximity contact data for their impacts on transmission models’ results under community and types of diseases. Methods: We examined the contact patterns derived from 3 data sets collected in 2016, with participants comprising students and staff from the University of Saskatchewan in Canada. Each of these 3 data sets used both Bluetooth beaconing and GPS localization on smartphones running the Ethica Data (Avicenna Research) app to collect sensor data about every 5 minutes over a month. We compared the structure of contact networks inferred from proximity contact data collected with the modalities of GPS colocating and Bluetooth beaconing. We assessed the impact of sensing modalities on the simulation results of transmission models informed by proximate contacts derived from sensing data. Specifically, we compared the incidence number, attack rate, and individual infection risks across simulation results of agent-based susceptible-exposed-infectious-removed transmission models of 4 different contagious diseases. We have demonstrated their differences with violin plots, 2-tailed t tests, and Kullback-Leibler divergence. Results: Both network structure analyses show visually salient differences in proximity contact data collected between GPS colocating and Bluetooth beaconing, regardless of the underlying population. Significant differences were found for the estimated attack rate based on distance threshold, measurement modality, and simulated disease. This finding demonstrates that the sensor modality used to trace contact can have a significant impact on the expected propagation of a disease through a population. The violin plots of attack rate and Kullback-Leibler divergence of individual infection risks demonstrated discernible differences for different sensing modalities, regardless of the underlying population and diseases. The results of the t tests on attack rate between different sensing modalities were mostly significant (P<.001). Conclusions: We show that the contact networks generated from these 2 measurement modalities are different and generate significantly different attack rates across multiple data sets and pathogens. While both modalities offer higher-resolution portraits of contact behavior than is possible with most traditional contact measures, the differential impact of measurement modality on the simulation outcome cannot be ignored and must be addressed in studies only using a single measure of contact in the future. %M 38422493 %R 10.2196/38170 %U https://www.jmir.org/2024/1/e38170 %U https://doi.org/10.2196/38170 %U http://www.ncbi.nlm.nih.gov/pubmed/38422493 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e52679 %T Rolling the DICE (Design, Interpret, Compute, Estimate): Interactive Learning of Biostatistics With Simulations %A Thiesmeier,Robert %A Orsini,Nicola %+ Department of Global Public Health, Karolinska Institutet, Tomtebodavägen 18, Solna, 171 65, Sweden, 46 735779719, robert.thiesmeier@ki.se %K learning statistics %K Monte Carlo simulation %K simulation-based learning %K survival analysis %K Weibull %D 2024 %7 15.4.2024 %9 Viewpoint %J JMIR Med Educ %G English %X Despite the increasing relevance of statistics in health sciences, teaching styles in higher education are remarkably similar across disciplines: lectures covering the theory and methods, followed by application and computer exercises in given data sets. This often leads to challenges for students in comprehending fundamental statistical concepts essential for medical research. To address these challenges, we propose an engaging learning approach—DICE (design, interpret, compute, estimate)—aimed at enhancing the learning experience of statistics in public health and epidemiology. In introducing DICE, we guide readers through a practical example. Students will work in small groups to plan, generate, analyze, interpret, and communicate their own scientific investigation with simulations. With a focus on fundamental statistical concepts such as sampling variability, error probabilities, and the construction of statistical models, DICE offers a promising approach to learning how to combine substantive medical knowledge and statistical concepts. The materials in this paper, including the computer code, can be readily used as a hands-on tool for both teachers and students. %M 38619866 %R 10.2196/52679 %U https://mededu.jmir.org/2024/1/e52679 %U https://doi.org/10.2196/52679 %U http://www.ncbi.nlm.nih.gov/pubmed/38619866 %0 Journal Article %@ 2291-9279 %I JMIR Serious Games %V 12 %N %P e46789 %T Efficacy of a Virtual 3D Simulation–Based Digital Training Module for Building Dental Technology Students’ Long-Term Competency in Removable Partial Denture Design: Prospective Cohort Study %A Liu,KeXin %A Xu,YaQian %A Ma,ChaoYi %A Yu,Na %A Tan,FaBing %A Li,Yi %A Bai,YaXin %A Fu,XiaoMing %A Wan,JiaWu %A Fan,DongQi %A Yin,HuBin %A Chen,MeiXi %A Chen,HongJi %A Jiang,Lin %A Song,JinLin %A Ji,Ping %A Zhao,XiaoHan %A Pang,MengWei %K removable partial denture %K RPD %K virtual simulation %K dental technology %K computer-aided design %K CAD %K clinical practice %K efficacy %K cohort study %K digital training %K training %K dentistry %K treatment %K design %K virtual %K assessment %D 2024 %7 5.4.2024 %9 %J JMIR Serious Games %G English %X Background: Removable partial denture (RPD) design is crucial to long-term success in dental treatment, but shortcomings in RPD design training and competency acquisition among dental students have persisted for decades. Digital production is increasing in prevalence in stomatology, and a digital RPD (D-RPD) module, under the framework of the certified Objective Manipulative Skill Examination of Dental Technicians (OMEDT) system reported in our previous work, may improve on existing RPD training models for students. Objective: We aimed to determine the efficacy of a virtual 3D simulation–based progressive digital training module for RPD design compared to traditional training. Methods: We developed a prospective cohort study including dental technology students at the Stomatology College of Chongqing Medical University. Cohort 1 received traditional RPD design training (7 wk). Cohort 2 received D-RPD module training based on text and 2D sketches (7 wk). Cohort 3 received D-RPD module pilot training based on text and 2D sketches (4 wk) and continued to receive training based on 3D virtual casts of real patients (3 wk). RPD design tests based on virtual casts were conducted at 1 month and 1 year after training. We collected RPD design scores and the time spent to perform each assessment. Results: We collected the RPD design scores and the time spent to perform each assessment at 1 month and 1 year after training. The study recruited 109 students, including 58 (53.2%) female and 51 male (56.8%) students. Cohort 1 scored the lowest and cohort 3 scored the highest in both tests (cohorts 1-3 at 1 mo: mean score 65.8, SD 21.5; mean score 81.9, SD 6.88; and mean score 85.3, SD 8.55, respectively; P<.001; cohorts 1-3 at 1 y: mean score 60.3, SD 16.7; mean score 75.5, SD 3.90; and mean score 90.9, SD 4.3, respectively; P<.001). The difference between cohorts in the time spent was not statistically significant at 1 month (cohorts 1-3: mean 2407.8, SD 1370.3 s; mean 1835.0, SD 1329.2 s; and mean 1790.3, SD 1195.5 s, respectively; P=.06) but was statistically significant at 1 year (cohorts 1-3: mean 2049.16, SD 1099.0 s; mean 1857.33, SD 587.39 s; and mean 2524.3, SD 566.37 s, respectively; P<.001). Intracohort comparisons indicated that the differences in scores at 1 month and 1 year were not statistically significant for cohort 1 (95% CI –2.1 to 13.0; P=.16), while cohort 3 obtained significantly higher scores 1 year later (95% CI 2.5-8.7; P=.001), and cohort 2 obtained significantly lower scores 1 year later (95% CI –8.8 to –3.9; P<.001). Conclusions: Cohort 3 obtained the highest score at both time points with retention of competency at 1 year, indicating that progressive D-RPD training including virtual 3D simulation facilitated improved competency in RPD design. The adoption of D-RPD training may benefit learning outcomes. %R 10.2196/46789 %U https://games.jmir.org/2024/1/e46789 %U https://doi.org/10.2196/46789 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e54401 %T Development of a Clinical Simulation Video to Evaluate Multiple Domains of Clinical Competence: Cross-Sectional Study %A Shikino,Kiyoshi %A Nishizaki,Yuji %A Fukui,Sho %A Yokokawa,Daiki %A Yamamoto,Yu %A Kobayashi,Hiroyuki %A Shimizu,Taro %A Tokuda,Yasuharu %+ Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chiba, 2608677, Japan, 81 43 222 7171, kshikino@gmail.com %K discrimination index %K General Medicine In-Training Examination %K clinical simulation video %K postgraduate medical education %K video %K videos %K training %K examination %K examinations %K medical education %K resident %K residents %K postgraduate %K postgraduates %K simulation %K simulations %K diagnosis %K diagnoses %K diagnose %K general medicine %K general practice %K general practitioner %K skill %K skills %D 2024 %7 29.2.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Medical students in Japan undergo a 2-year postgraduate residency program to acquire clinical knowledge and general medical skills. The General Medicine In-Training Examination (GM-ITE) assesses postgraduate residents’ clinical knowledge. A clinical simulation video (CSV) may assess learners’ interpersonal abilities. Objective: This study aimed to evaluate the relationship between GM-ITE scores and resident physicians’ diagnostic skills by having them watch a CSV and to explore resident physicians’ perceptions of the CSV’s realism, educational value, and impact on their motivation to learn. Methods: The participants included 56 postgraduate medical residents who took the GM-ITE between January 21 and January 28, 2021; watched the CSV; and then provided a diagnosis. The CSV and GM-ITE scores were compared, and the validity of the simulations was examined using discrimination indices, wherein ≥0.20 indicated high discriminatory power and >0.40 indicated a very good measure of the subject’s qualifications. Additionally, we administered an anonymous questionnaire to ascertain participants’ views on the realism and educational value of the CSV and its impact on their motivation to learn. Results: Of the 56 participants, 6 (11%) provided the correct diagnosis, and all were from the second postgraduate year. All domains indicated high discriminatory power. The (anonymous) follow-up responses indicated that the CSV format was more suitable than the conventional GM-ITE for assessing clinical competence. The anonymous survey revealed that 12 (52%) participants found the CSV format more suitable than the GM-ITE for assessing clinical competence, 18 (78%) affirmed the realism of the video simulation, and 17 (74%) indicated that the experience increased their motivation to learn. Conclusions: The findings indicated that CSV modules simulating real-world clinical examinations were successful in assessing examinees’ clinical competence across multiple domains. The study demonstrated that the CSV not only augmented the assessment of diagnostic skills but also positively impacted learners’ motivation, suggesting a multifaceted role for simulation in medical education. %M 38421691 %R 10.2196/54401 %U https://mededu.jmir.org/2024/1/e54401 %U https://doi.org/10.2196/54401 %U http://www.ncbi.nlm.nih.gov/pubmed/38421691 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51596 %T Effects of a Rice-Farming Simulation Video Game on Nature Relatedness, Nutritional Status, and Psychological State in Urban-Dwelling Adults During the COVID-19 Pandemic: Randomized Waitlist Controlled Trial %A Lee,Seulki %A Yuh,Chisung %A Shin,Yu-Bin %A Lee,Heon-Jeong %A Lee,Young-Mee %A Lee,Jungsil %A Cho,Chul-Hyun %+ Department of Psychiatry, Korea University College of Medicine, 73 Goryeodae-ro Seongbuk-gu, Seoul, 02841, Republic of Korea, 82 0221993827, david0203@gmail.com %K video game %K digital intervention %K nature relatedness %K nutritional status %K psychological state %K COVID-19 %K urban-dwelling adults %D 2024 %7 22.1.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: During the COVID-19 pandemic, urban inhabitants faced significant challenges in maintaining connections with nature, adhering to nutritional guidelines, and managing mental well-being. Objective: Recognizing the urgent need for innovative approaches, this study was designed to explore the potential benefits of a specific digital intervention, the rice-farming simulation game Sakuna: Of Rice and Ruin, for nature relatedness, nutritional behaviors, and psychological well-being. Methods: A total of 66 adults without any prior major psychiatric disorders residing in an urban area were recruited for the study. They were randomly assigned to 2 groups through block randomization: the immediate intervention group (IIG; 34/66, 52%) and the waitlist group (32/66, 48%). Participants in the IIG were instructed to play the game for at least 4 days per week for 3 weeks, with each session lasting from 30 minutes to 3 hours. Assessments were performed at baseline, week 1, and week 3. The Nature Relatedness Scale (NR) and Nutrition Quotient Scale were used to evaluate nature relatedness and nutritional state, respectively. Furthermore, psychological state was assessed using the World Health Organization Quality of Life–Brief Version (WHOQOL-BREF), Brief Fear of Negative Evaluation Scale, Social Avoidance and Distress Scale, Toronto Alexithymia Scale, State-Trait Anxiety Inventory, Center for Epidemiologic Studies Depression Scale Revised, and Korean Resilience Quotient. Results: This study’s results revealed significant time interactions between the IIG and waitlist group for both the total NR score (P=.001) and the score of the self subdomain of NR (P<.001), indicating an impact of the game on nature relatedness. No group×time interactions were found for the total Nutrition Quotient Scale and subdomain scores, although both groups showed increases from baseline. For psychological state, a significant group×time interaction was observed in the total WHOQOL-BREF score (P=.049), suggesting an impact of the game on quality of life. The psychological (P=.01), social (P=.003), and environmental (P=.04) subdomains of the WHOQOL-BREF showed only a significant time effect. Other psychological scales did not display any significant changes (all P>.05). Conclusions: Our findings suggest that the rice-farming game intervention might have positive effects on nature relatedness, nature-friendly dietary behaviors, quality of life, anxiety, depression, interpersonal relationships, and resilience among urban adults during the COVID-19 pandemic. The impact of pronature games in confined urban environments provides valuable evidence of how digital technologies can be used to enhance urban residents’ affinity for nature and psychological well-being. This understanding can be extended in the future to other digital platforms, such as metaverses. Trial Registration: Clinical Research Information Service (CRIS) KCT0007657; http://tinyurl.com/yck7zxp7 %M 38252464 %R 10.2196/51596 %U https://www.jmir.org/2024/1/e51596 %U https://doi.org/10.2196/51596 %U http://www.ncbi.nlm.nih.gov/pubmed/38252464 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e53961 %T A Generative Pretrained Transformer (GPT)–Powered Chatbot as a Simulated Patient to Practice History Taking: Prospective, Mixed Methods Study %A Holderried,Friederike %A Stegemann–Philipps,Christian %A Herschbach,Lea %A Moldt,Julia-Astrid %A Nevins,Andrew %A Griewatz,Jan %A Holderried,Martin %A Herrmann-Werner,Anne %A Festl-Wietek,Teresa %A Mahling,Moritz %+ Tübingen Institute for Medical Education, Eberhard Karls University, Elfriede-Aulhorn-Str 10, Tübingen, 72076, Germany, 49 7071 2973715, friederike.holderried@med.uni-tuebingen.de %K simulated patient %K GPT %K generative pretrained transformer %K ChatGPT %K history taking %K medical education %K documentation %K history %K simulated %K simulation %K simulations %K NLP %K natural language processing %K artificial intelligence %K interactive %K chatbot %K chatbots %K conversational agent %K conversational agents %K answer %K answers %K response %K responses %K human computer %K human machine %K usability %K satisfaction %D 2024 %7 16.1.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Communication is a core competency of medical professionals and of utmost importance for patient safety. Although medical curricula emphasize communication training, traditional formats, such as real or simulated patient interactions, can present psychological stress and are limited in repetition. The recent emergence of large language models (LLMs), such as generative pretrained transformer (GPT), offers an opportunity to overcome these restrictions Objective: The aim of this study was to explore the feasibility of a GPT-driven chatbot to practice history taking, one of the core competencies of communication. Methods: We developed an interactive chatbot interface using GPT-3.5 and a specific prompt including a chatbot-optimized illness script and a behavioral component. Following a mixed methods approach, we invited medical students to voluntarily practice history taking. To determine whether GPT provides suitable answers as a simulated patient, the conversations were recorded and analyzed using quantitative and qualitative approaches. We analyzed the extent to which the questions and answers aligned with the provided script, as well as the medical plausibility of the answers. Finally, the students filled out the Chatbot Usability Questionnaire (CUQ). Results: A total of 28 students practiced with our chatbot (mean age 23.4, SD 2.9 years). We recorded a total of 826 question-answer pairs (QAPs), with a median of 27.5 QAPs per conversation and 94.7% (n=782) pertaining to history taking. When questions were explicitly covered by the script (n=502, 60.3%), the GPT-provided answers were mostly based on explicit script information (n=471, 94.4%). For questions not covered by the script (n=195, 23.4%), the GPT answers used 56.4% (n=110) fictitious information. Regarding plausibility, 842 (97.9%) of 860 QAPs were rated as plausible. Of the 14 (2.1%) implausible answers, GPT provided answers rated as socially desirable, leaving role identity, ignoring script information, illogical reasoning, and calculation error. Despite these results, the CUQ revealed an overall positive user experience (77/100 points). Conclusions: Our data showed that LLMs, such as GPT, can provide a simulated patient experience and yield a good user experience and a majority of plausible answers. Our analysis revealed that GPT-provided answers use either explicit script information or are based on available information, which can be understood as abductive reasoning. Although rare, the GPT-based chatbot provides implausible information in some instances, with the major tendency being socially desirable instead of medically plausible information. %M 38227363 %R 10.2196/53961 %U https://mededu.jmir.org/2024/1/e53961 %U https://doi.org/10.2196/53961 %U http://www.ncbi.nlm.nih.gov/pubmed/38227363 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e45723 %T Social and Ethical Implications of Digital Crisis Technologies: Case Study of Pandemic Simulation Models During the COVID-19 Pandemic %A Bartl,Gabriel %+ Centre Marc Bloch, Friedrichstr 191, Berlin, 10117, Germany, 49 30 209370700, gabriel.bartl@cmb.hu-berlin.de %K public health technologies %K simulation models %K algorithmic governance %K preparedness %K crisis, uncertainty, and ignorance %K social implications of mathematical modeling %K normativity %K transparency %K legitimacy %D 2024 %7 16.1.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Responses to public health crises are increasingly technological in nature, as the prominence of COVID-19–related statistics and simulations amply demonstrates. However, the use of technologies is preconditional and has various implications. These implications can not only affect acceptance but also challenge the acceptability of these technologies with regard to the ethical and normative dimension. Objective: This study focuses on pandemic simulation models as algorithmic governance tools that played a central role in political decision-making during the COVID-19 pandemic. To assess the social implications of pandemic simulation models, the premises of data collection, sorting, and evaluation must be disclosed and reflected upon. Consequently, the social construction principles of digital health technologies must be revealed and examined for their effects with regard to social, ethical, and ultimately political issues. Methods: This case study starts with a systematization of different simulation approaches to create a typology of pandemic simulation models. On the basis of this, various properties, functions, and challenges of these simulation models are revealed and discussed in detail from a socioscientific point of view. Results: The typology of pandemic simulation methods reveals the diversity of model-driven handling of pandemic threats. However, it is reasonable to assume that the use of simulation models could increasingly shift toward agent-based or artificial intelligence models in the future, thus promoting the logic of algorithmic decision-making in response to public health crises. As algorithmic decision-making focuses more on predicting future dynamics than statistical practices of assessing pandemic events, this study discusses this development in detail, resulting in an operationalized overview of the key social and ethical issues related to pandemic crisis technologies. Conclusions: This study identifies 3 major recommendations for the future of pandemic crisis technologies. %M 38227361 %R 10.2196/45723 %U https://www.jmir.org/2024/1/e45723 %U https://doi.org/10.2196/45723 %U http://www.ncbi.nlm.nih.gov/pubmed/38227361 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46639 %T Scenario-Based e-Simulation Design for Global Health Education: Theoretical Foundation and Practical Recommendations %A Bahattab,Awsan %A Caviglia,Marta %A Martini,Daniela %A Hubloue,Ives %A Della Corte,Francesco %A Ragazzoni,Luca %+ Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health (CRIMEDIM), Università del Piemonte Orientale, Via Lanino, 1, Novara, 28100, Italy, 39 333 9252944, awsan.bahattab@uniupo.it %K global health %K education %K medical %K computer simulation %K scenario-based learning %K scenario-based e-simulation %K simulation %K design %K education %K training %K development %K medical educator %D 2023 %7 30.10.2023 %9 Viewpoint %J J Med Internet Res %G English %X Electronic simulation (e-simulation)—particularly scenario-based e-simulation (SBES)—is an increasingly used, promising educational strategy for global health education that can address gaps in training access, effectiveness, and cost. However, there is little guidance for educators on how to develop an SBES, and guidance is lacking outside the clinical context. Moreover, literature on medical education rarely uses the theoretical basis for e-simulation design and development, including for SBES. Hence, we aim to differentiate and describe the concept, design elements, and theoretical basis of SBES with examples from different topics in global health. In addition to enhancing the understanding of the potential of SBES for global health education, this manuscript also provides practical recommendations for global health educators in designing and developing SBESs based on the existing literature and authors’ experiences. Overall, this manuscript will be useful for global health educators as well as other medical educators seeking to develop an SBES for similar skill sets. %M 37902810 %R 10.2196/46639 %U https://www.jmir.org/2023/1/e46639 %U https://doi.org/10.2196/46639 %U http://www.ncbi.nlm.nih.gov/pubmed/37902810 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 12 %N %P e48381 %T Three-Dimensional Virtual Reconstructions of Shoulder Movements Using Computed Tomography Images: Model Development %A Kim,Yu-Hee %A Park,In %A Cho,Soo Buem %A Yang,Seoyon %A Kim,Il %A Lee,Kyong-Ha %A Choi,Kwangnam %A Han,Seung-Ho %+ Department of Anatomy, Ewha Womans University College of Medicine, 25 Magokdong-ro 2-gil, Gangseo-gu, Seoul, 07804, Republic of Korea, 82 2 6986 2601, sanford@ewha.ac.kr %K human digital twin %K musculoskeletal twin %K shoulder movement %K visualization application %K digital twin %K musculoskeletal %K visualization %K movement %K joint %K shoulder %K tomography %K development %K animation %K animated %K anatomy %K anatomical %K digital health %K representation %K simulation %K virtual %D 2023 %7 5.10.2023 %9 Research Letter %J Interact J Med Res %G English %X %M 37796554 %R 10.2196/48381 %U https://www.i-jmr.org/2023/1/e48381 %U https://doi.org/10.2196/48381 %U http://www.ncbi.nlm.nih.gov/pubmed/37796554 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e49372 %T Health Care and Social Work Students’ Experiences With a Virtual Reality Simulation Learning Activity: Qualitative Study %A Helle,Nikolina %A Vikman,Miriam Dubland %A Dahl-Michelsen,Tone %A Lie,Silje Stangeland %+ Institute of Health, Faculty of Health Sciences, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, 47 990 90 005, miriam.vikman@vid.no %K virtual reality %K virtual reality simulation %K learning %K experiences %K health care and social work %K higher education %K health care %K social work %D 2023 %7 20.9.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality is used to an increasing extent in various fields and is now making inroads into health and social education. Virtual reality simulation can provide a safe and controlled environment for students to practice and master skills that are transferable to real-world situations without putting patients, clients, or themselves at risk of any harm. Virtual reality simulation using 360° videos represents a novel approach to simulation in health care and social work education, and this inspired our interest in exploring students’ experiences with such a learning activity. Objective: The aim of this study was to explore occupational therapy, social education, nursing, and social work students’ experiences with virtual reality simulation as a learning activity in an interdisciplinary subject. Methods: The data were collected through 6 semistructured focus groups with 28 students. We conducted the focus groups after the students from the 4 education programs had participated in the virtual reality simulation at 3 campuses at a specialized university in Norway. Each focus group interview was facilitated by 1 moderator and 1 facilitator, a combination of experienced researchers and novices. We followed a qualitative design using the 6-step thematic analysis described by Braun and Clarke. Results: The analysis revealed 3 overall themes for students’ experiences with the virtual reality simulation. The first theme, 360° videos provide observations for individual learning, illustrates how learning can take place through the students’ experiences with sensory inputs and observations from the 360° videos. Students experienced that the video enabled them to individually reflect and achieve learning from what was considered a clinically relevant video. The second theme, 360° videos activate emotional learning, demonstrates how the students experienced emotional engagement when watching the 360° videos. The degree of realism provided in the video was considered as important for the students’ learning. The last theme, Debrief sessions enhance comprehensive learning, pinpoints how the students experienced learning through reflective discussions with other students after watching the 360° videos. Students claimed this process to be a vital part of the learning activity. Conclusions: Virtual reality simulation represents a promising learning activity to enhance the professional learning of health care and social work students. It offers opportunities for individualized learning through observations, and it also engages students emotionally in the learning process. The combination of 360° videos and group discussions in virtual reality appears promising to enhance professional learning outcomes and competence, which may contribute to improved health care and social work services. %M 37728988 %R 10.2196/49372 %U https://mededu.jmir.org/2023/1/e49372 %U https://doi.org/10.2196/49372 %U http://www.ncbi.nlm.nih.gov/pubmed/37728988 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45969 %T Game Elements in the Design of Simulations in Military Trauma Management Training: Protocol for a Systematic Review %A Stathakarou,Natalia %A Kononowicz,Andrzej A %A Swain,Cara %A Karlgren,Klas %+ Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18A, Solna, Stockholm, 171 77, Sweden, 46 8 524 852 98, natalia.stathakarou@ki.se %K gamification %K game elements %K military medicine %K trauma %K medical education %K military training %K systematic review %K game %K gaming %K simulation %D 2023 %7 8.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Military trauma teams are commonly operating in civilian hospitals during peacetime; in a war situation they must adjust their practices to the austere conditions. Simulations can replicate austere conditions to allow training in a safe environment that tolerates errors. Gamification, understood as the use of game elements to motivate and engage learners in nongame contexts, is gaining interest in medical education and military training. Applying game elements in the design of military trauma management simulations has the potential to provide learners with active learning opportunities and prepare them for providing medical services under austere conditions. Although gamification is known for its engaging and motivational benefits, there are controversies about its pedagogical value. The controversies can be attributed to the fact that various gamification strategies may consist of a different combination of game elements, leading to different outcomes. Objective: This systematic review aims to understand how game elements are used in the design of simulations in military trauma management training and their reported outcomes. Methods: We have designed a search strategy for the purpose of the review. Two researchers will independently assess the identified studies based on the defined inclusion and exclusion criteria. The selection process will be represented using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. The search will be repeated and updated as necessary prior to publication of the review. Two reviewers will independently extract and manage the data for each of the articles using a structured data extraction form. Any disagreement that arises between reviewers will be resolved through discussion, and a third review author will be consulted when needed. We are going to conduct a thematic synthesis of the extracted game element descriptions. The results are going to be presented in a diagrammatic or tabular form, alongside a narrative summary. The quality of the studies will be assessed. Results: We implemented and tested the developed search strategy in May 2023. We retrieved 1168 study abstracts, which were reduced to 630 abstracts after deduplication. We have piloted the screening on 20% (126/630) of the identified abstracts in groups of 2 reviewers. Conclusions: Although gamification has the potential to motivate learners in various ways, there is a lack of understanding about specific game elements and how they can inform instructional design in different contexts. Our findings will increase the understanding of how game elements are used in the design of simulations in military trauma management training and, thus, contribute to more effective development of future simulations. International Registered Report Identifier (IRRID): DERR1-10.2196/45969 %M 37682596 %R 10.2196/45969 %U https://www.researchprotocols.org/2023/1/e45969 %U https://doi.org/10.2196/45969 %U http://www.ncbi.nlm.nih.gov/pubmed/37682596 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e48586 %T The Impact of Web-Based Continuing Medical Education Using Patient Simulation on Real-World Treatment Selection in Type 2 Diabetes: Retrospective Case-Control Analysis %A Lucero,Katie Stringer %A Larkin,Amy %A Zakharkin,Stanislav %A Wysham,Carol %A Anderson,John %+ Medscape, LLC, 395 Hudson St, New York, NY, 10014, United States, 1 212 301 6782, klucero@webmd.net %K continuing medical education %K virtual patient simulation %K real-world evidence %K evaluation %K outcomes %K diabetes education %K medical education %K type 2 diabetes %K web-based learning %K web-based education %D 2023 %7 29.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Despite guidelines recommending the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in certain patients with type 2 diabetes (T2D), they are not being prescribed for many of these patients. Web-based continuing medical education (CME) patient simulations have been used to identify clinicians’ practice gaps and improve clinical decision-making as measured within a simulation, but the impact of this format on real-world treatment has not been researched. Objective: This study aimed to evaluate the effect of a simulation-based CME intervention on real-world use of GLP-1 RAs by endocrinologists and primary care physicians. Methods: Two evaluation phases of the CME simulation were conducted: phase I, the CME simulation phase, was a paired, pre-post study of 435 physician learners in the United States; and phase II, the real-world phase, was a retrospective, matched case-control study of 157 of the 435 physicians who had claims data available for the study period. Results: Phase I CME results showed a 29 percentage point increase in correct decisions from pre- to postfeedback (178/435, 40.9% to 304/435, 69.9%; P<.001) in selecting treatment that addresses both glycemic control and cardiovascular event protection. Phase II results showed that 39 of 157 (24.8%) physicians in the intervention group increased use of GLP-1 RAs, compared to 20 of 157 (12.7%) in the comparison group. Being in the intervention group predicted GLP-1 RA use after education (odds ratio 4.49; 95% CI 1.45-13.97; P=.001). Conclusions: A web-based CME simulation focused on secondary prevention of cardiovascular events in a patient with T2D was associated with increased use of evidence-based treatment selection in the real world. %M 37642994 %R 10.2196/48586 %U https://mededu.jmir.org/2023/1/e48586 %U https://doi.org/10.2196/48586 %U http://www.ncbi.nlm.nih.gov/pubmed/37642994 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e43710 %T Teaching Palliative Care to Emergency Medicine Residents Using Gamified Deliberate Practice-Based Simulation: Palliative Gaming Simulation Study %A Stanich,Jessica %A Sunga,Kharmene %A Loprinzi-Brauer,Caitlin %A Ginsburg,Alexander %A Ingram,Cory %A Bellolio,Fernanda %A Cabrera,Daniel %+ Department of Emergency Medicine, Mayo Clinic, 200 First Steet SW, Rochester, MN, 55905, United States, 1 5072554137, jstans44@gmail.com %K palliative care %K emergency medicine %K gaming simulation %K resident education %K medical education %K residency %K end of life %K palliative %K dying %K death %K interpersonal skill %D 2023 %7 16.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Emergency departments (EDs) care for many patients nearing the end of life with advanced serious illnesses. Simulation training offers an opportunity to teach physicians the interpersonal skills required to manage end-of-life care. Objective: We hypothesized a gaming simulation of an imminently dying patient using the LIVE. DIE. REPEAT (LDR) format, would be perceived as an effective method to teach end-of-life communication and palliative care management skills. Methods: This was a gaming simulation replicating the experience of caring for a dying patient with advanced serious illness in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress, with a previously established goal of comfort care. The gaming simulation game was divided into 4 stages, and at each level, learners were tasked with completing 1 critical action. The gaming simulation was designed using the LDR serious game scheme in which learners are allowed infinite opportunities to progress through defined stages depicting a single patient scenario. If learners successfully complete the predetermined critical actions of each stage, the game is paused, and there is a debriefing to reinforce knowledge or skills before progressing to the next stage of the gaming simulation. Conversely, if learners do not achieve the critical actions, the game is over, and learners undergo debriefing before repeating the failed stage with an immediate transition into the next. We used the Simulation Effectiveness Tool–Modified survey to evaluate perceived effectiveness in teaching end-of-life management. Results: Eighty percent (16/20) of residents completed the Simulation Effectiveness Tool–Modified survey, and nearly 100% (20/20) either strongly or somewhat agreed that the gaming simulation improved their skills and confidence at the end of life in the following dimensions: (1) better prepared to respond to changes in condition, (2) more confident in assessment skills, (3) teaching patients, (4) reporting to the health care team, (5) empowered to make clinical decisions, and (6) able to prioritize care and interventions. All residents felt the debriefing contributed to learning and provided opportunities to self-reflect. All strongly or somewhat agree that they felt better prepared to respond to changes in the patient’s condition, had a better understanding of pathophysiology, were more confident on their assessment skills, and had a better understanding of the medications and therapies after the gaming simulation. A total of 88% (14/16) of them feel more empowered to make clinical decisions. After completing the gaming simulation, 88% (14/16) of residents strongly agreed that they would feel more confident communicating with a patient and prioritizing care interventions in this context. Conclusions: This palliative gaming simulation using the LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management. %M 37585258 %R 10.2196/43710 %U https://mededu.jmir.org/2023/1/e43710 %U https://doi.org/10.2196/43710 %U http://www.ncbi.nlm.nih.gov/pubmed/37585258 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e44361 %T Student and Faculty Perspectives on the Usefulness and Usability of a Digital Health Educational Tool to Teach Standardized Assessment of Persons After Stroke: Mixed Methods Study %A Deutsch,Judith E %A Palmieri,John L %A Gorin,Holly %A Wendell,Augustus %A Wohn,Donghee Yvette %A Damodaran,Harish %+ Rivers Lab Department of Rehabilitation & Movement Sciences, School of Health Professions, Rutgers, 65 Bergen Street, Newark, NJ, 07101, United States, 1 9739722373, deutsch@rutgers.edu %K physical therapy %K education %K teaching tool %K simulation-based learning %K computer-aided instruction %K standardized assessment %K clinical reasoning %K sensors %D 2023 %7 10.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: The VSTEP Examination Suite is a collection of evidence-based standardized assessments for persons after stroke. It was developed by an interdisciplinary team in collaboration with clinician users. It consists of 5 standardized assessments: 2 performance-based tests using the Kinect camera (Microsoft Corp) to collect kinematics (5-Time Sit-to-Stand and 4-Square Test); 2 additional performance-based tests (10-Meter Walk Test and 6-Minute Walk Test); and 1 patient-reported outcome measure, the Activities-Specific Balance Confidence Scale. Objective: This study aimed to describe the development of the VSTEP Examination Suite and its evaluation as an educational tool by physical therapy students and faculty to determine its usefulness and usability. Methods: A total of 6 students from a Doctor of Physical Therapy program in the United States and 6 faculty members who teach standardized assessments in different physical therapy programs from the United States and Israel were recruited by convenience sampling to participate in the study. They interacted with the system using a talk-aloud procedure either in pairs or individually. The transcripts of the sessions were coded deductively (by 3 investigators) with a priori categories of usability and usefulness, and comments were labeled as negative or positive. The frequencies of the deductive themes of usefulness and usability were tested for differences between faculty and students using a Wilcoxon rank sum test. A second round of inductive coding was performed by 3 investigators guided by theories of technology adoption, clinical reasoning, and education. Results: The faculty members’ and students’ positive useful comments ranged from 83% (10/12) to 100%. There were no significant differences in usefulness comments between students and faculty. Regarding usability, faculty and students had the lowest frequency of positive comments for the 10-Meter Walk Test (5/10, 50%). Students also reported a high frequency of negative comments on the 4-Square Test (9/21, 43%). Students had a statistically significantly higher number of negative usability comments compared with faculty (W=5.7; P=.02), specifically for the 5-Time Sit-to-Stand (W=5.3; P=.02). Themes emerged related to variable knowledge about the standardized tests, value as a teaching and learning tool, technology being consistent with clinical reasoning in addition to ensuring reliability, expert-to-novice clinical reasoning (students), and usability. Conclusions: The VSTEP Examination Suite was found to be useful by both faculty and students. Reasons for perceived usefulness had some overlap, but there were also differences based on role and experience. Usability testing revealed opportunities for technology refinement. The development of the technology by interdisciplinary teams and testing with multiple types of users may increase adoption. %M 37561552 %R 10.2196/44361 %U https://mededu.jmir.org/2023/1/e44361 %U https://doi.org/10.2196/44361 %U http://www.ncbi.nlm.nih.gov/pubmed/37561552 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e38282 %T Transfer Validity of Pediatric Supracondylar Humeral Fracture Pin Placement Practice on In-Theater Performance by Orthopedic Trainees Using an Augmented Reality Simulator: Protocol for a Pilot Interventional Cohort Study With a Retrospective Comparator Cohort %A Guo,Joyce %A Blyth,Phil %A Clifford,Kari %A Hooper,Nikki %A Crawford,Haemish %+ Department of the Dean, Otago Medical School, University of Otago, 201 Great King Street, Central Dunedin, Dunedin, 9016, New Zealand, 64 273635352, joyce.guo@postgrad.otago.ac.nz %K pediatric orthopedics %K augmented reality simulator %K supracondylar humeral fractures %K closed reduction and percutaneous pinning %K transfer validity %K fracture %K surgeons %K education %K practice %K trainees %K pediatric %K orthopedic %K training %K surgical procedure %D 2023 %7 2.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray–guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of “see one, do one, teach one” are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients. Objective: This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees. Methods: This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort’s performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training. Results: As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021). Conclusions: This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb International Registered Report Identifier (IRRID): DERR1-10.2196/38282 %M 37531159 %R 10.2196/38282 %U https://www.researchprotocols.org/2023/1/e38282 %U https://doi.org/10.2196/38282 %U http://www.ncbi.nlm.nih.gov/pubmed/37531159 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e45538 %T How Augmenting Reality Changes the Reality of Simulation: Ethnographic Analysis %A Loeb,Daniel %A Shoemaker,Jamie %A Parsons,Allison %A Schumacher,Daniel %A Zackoff,Matthew %+ Division of Critical Care, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Division of Pediatric Critical Care, C Building, 5th Floor, 3333 Burnet Ave, Cincinnati, OH, 45229, United States, 1 513 636 4825, daniel.loeb@cchmc.org %K simulation %K augmented reality %K computerized mannequin %K video review %D 2023 %7 30.6.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Simulation-based medical education (SBME) provides key medical training for providers to safely and ethically practice high-risk events. Augmented reality (AR)–enhanced simulation projects digital images of realistic examination findings into a participant’s field of view, which allows nuanced physical examination findings such as respiratory distress and skin perfusion to be prominently displayed. It is unknown how AR compares to traditional mannequin (TM)–based simulation with regard to influencing participant attention and behavior. Objective: The purpose of this study is to use video-based focused ethnography—a problem-focused, context-specific descriptive form of research whereby the research group collectively analyzes and interprets a subject of interest—to compare and categorize provider attention and behavior during TM and AR and provide suggestions for educators looking to delineate these 2 modalities. Methods: Twenty recorded interprofessional simulations (10 TM, 10 AR) featuring a decompensating child were evaluated through video-based focused ethnography. A generative question was posed: “How do the attention and behavior of participants vary based on the simulation modality?” Iterative data collection, analysis, and pattern explanation were performed by a review team spanning critical care, simulation, and qualitative expertise. Results: The attention and behavior of providers during TM and AR simulation clustered into three core themes: (1) focus and attention, (2) suspension of disbelief, and (3) communication. Participants focused on the mannequin during AR, especially when presented with changing physical examination findings, whereas in TM, participants focused disproportionately on the cardiorespiratory monitor. When participants could not trust what they were seeing or feeling in either modality, the illusion of realism was lost. In AR, this manifested as being unable to physically touch a digital mannequin, and in TM, participants were often unsure if they could trust their physical examination findings. Finally, communication differed, with calmer and clearer communication during TM, while AR communication was more chaotic. Conclusions: The primary differences clustered around focus and attention, suspension of disbelief, and communication. Our findings provide an alternative methodology to categorize simulation, shifting focus from simulation modality and fidelity to participant behavior and experience. This alternative categorization suggests that TM simulation may be superior for practical skill acquisition and the introduction of communication strategies for novice learners. Meanwhile, AR simulation offers the opportunity for advanced training in clinical assessment. Further, AR could be a more appropriate platform for assessing communication and leadership by more experienced clinicians due to the generated environment being more representative of decompensation events. Further research will explore the attention and behavior of providers in virtual reality–based simulations and real-life resuscitations. Ultimately, these profiles will inform the development of an evidence-based guide for educators looking to optimize simulation-based medical education by pairing learning objectives with the ideal simulation modality. %M 37389920 %R 10.2196/45538 %U https://mededu.jmir.org/2023/1/e45538 %U https://doi.org/10.2196/45538 %U http://www.ncbi.nlm.nih.gov/pubmed/37389920 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44042 %T Development of an Anticipatory Triage-Ranking Algorithm Using Dynamic Simulation of the Expected Time Course of Patients With Trauma: Modeling and Simulation Study %A Sigle,Manuel %A Berliner,Leon %A Richter,Erich %A van Iersel,Mart %A Gorgati,Eleonora %A Hubloue,Ives %A Bamberg,Maximilian %A Grasshoff,Christian %A Rosenberger,Peter %A Wunderlich,Robert %+ University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Hoppe-Seyler-Str.3, Tübingen, 72076, Germany, 49 7071 29 86564, Robert.Wunderlich@med.uni-tuebingen.de %K novel triage algorithm %K patient with trauma %K dynamic patient simulation %K mathematic model %K artificial patient database %K semisupervised generation of patients with artificial trauma %K high-dimensional analysis of patient database %K Germany %K algorithm %K trauma %K proof-of-concept %K model %K emergency %K triage %K simulation %K urgency %K urgent %K severity %K rank %K vital sign %D 2023 %7 15.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: In cases of terrorism, disasters, or mass casualty incidents, far-reaching life-and-death decisions about prioritizing patients are currently made using triage algorithms that focus solely on the patient’s current health status rather than their prognosis, thus leaving a fatal gap of patients who are under- or overtriaged. Objective: The aim of this proof-of-concept study is to demonstrate a novel approach for triage that no longer classifies patients into triage categories but ranks their urgency according to the anticipated survival time without intervention. Using this approach, we aim to improve the prioritization of casualties by respecting individual injury patterns and vital signs, survival likelihoods, and the availability of rescue resources. Methods: We designed a mathematical model that allows dynamic simulation of the time course of a patient’s vital parameters, depending on individual baseline vital signs and injury severity. The 2 variables were integrated using the well-established Revised Trauma Score (RTS) and the New Injury Severity Score (NISS). An artificial patient database of unique patients with trauma (N=82,277) was then generated and used for analysis of the time course modeling and triage classification. Comparative performance analysis of different triage algorithms was performed. In addition, we applied a sophisticated, state-of-the-art clustering method using the Gower distance to visualize patient cohorts at risk for mistriage. Results: The proposed triage algorithm realistically modeled the time course of a patient’s life, depending on injury severity and current vital parameters. Different casualties were ranked by their anticipated time course, reflecting their priority for treatment. Regarding the identification of patients at risk for mistriage, the model outperformed the Simple Triage And Rapid Treatment’s triage algorithm but also exclusive stratification by the RTS or the NISS. Multidimensional analysis separated patients with similar patterns of injuries and vital parameters into clusters with different triage classifications. In this large-scale analysis, our algorithm confirmed the previously mentioned conclusions during simulation and descriptive analysis and underlined the significance of this novel approach to triage. Conclusions: The findings of this study suggest the feasibility and relevance of our model, which is unique in terms of its ranking system, prognosis outline, and time course anticipation. The proposed triage-ranking algorithm could offer an innovative triage method with a wide range of applications in prehospital, disaster, and emergency medicine, as well as simulation and research. %M 37318826 %R 10.2196/44042 %U https://www.jmir.org/2023/1/e44042 %U https://doi.org/10.2196/44042 %U http://www.ncbi.nlm.nih.gov/pubmed/37318826 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e23287 %T Current Implementation Outcomes of Digital Surgical Simulation in Low- and Middle-Income Countries: Scoping Review %A Mahajan,Arnav %A Hawkins,Austin %+ Department of Medicine, University College Cork, Brookfield Health Sciences Complex, Cork City, T12 AK54, Ireland, 353 833517426, arnavmahajan99@outlook.com %K adaptation %K digital surgery %K global surgery %K simulation %K surgery %K systematic review %K technology %K video game %D 2023 %7 15.6.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Digital surgical simulation and telecommunication provides an attractive option for improving surgical skills, widening access to training, and improving patient outcomes; however, it is unclear whether sufficient simulations and telecommunications are accessible, effective, or feasible in low- and middle-income countries (LMICs). Objective: This study aims to determine which types of surgical simulation tools have been most widely used in LMICs, how surgical simulation technology is being implemented, and what the outcomes of these efforts have been. We also offer recommendations for the future development of digital surgical simulation implementation in LMICs. Methods: We searched PubMed, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, and the Central Register of Controlled Trials to look for qualitative studies in published literature discussing implementation and outcomes of surgical simulation training in LMICs. Eligible papers involved surgical trainees or practitioners who were based in LMICs. Papers that include allied health care professionals involved in task sharing were excluded. We focused specifically on digital surgical innovations and excluded flipped classroom models and 3D models. Implementation outcome had to be reported according to Proctor’s taxonomy. Results: This scoping review examined the outcomes of digital surgical simulation implementation in LMICs for 7 papers. The majority of participants were medical students and residents who were identified as male. Participants rated surgical simulators and telecommunications devices highly for acceptability and usefulness, and they believed that the simulators increased their anatomical and procedural knowledge. However, limitations such as image distortion, excessive light exposure, and video stream latency were frequently reported. Depending on the product, the implementation cost varied between US $25 and US $6990. Penetration and sustainability are understudied implementation outcomes, as all papers lacked long-term monitoring of the digital surgical simulations. Most authors are from high-income countries, suggesting that innovations are being proposed without a clear understanding of how they can be incorporated into surgeons’ practical training. Overall, the study indicates that digital surgical simulation is a promising tool for medical education in LMICs; however, additional research is required to address some of the limitations in order to achieve successful implementation, unless scaling efforts prove futile. Conclusions: This study indicates that digital surgical simulation is a promising tool for medical education in LMICs, but further research is necessary to address some of the limitations and ensure successful implementation. We urge more consistent reporting and understanding of implementation of science approaches in the development of digital surgical tools, as this is the critical factor that will determine whether we are able to meet the 2030 goals for surgical training in LMICs. Sustainability of implemented digital surgical tools is a pain point that must be focused on if we are to deliver digital surgical simulation tools to the populations that demand them the most. %M 37318901 %R 10.2196/23287 %U https://mededu.jmir.org/2023/1/e23287 %U https://doi.org/10.2196/23287 %U http://www.ncbi.nlm.nih.gov/pubmed/37318901 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e40040 %T Technology Acceptance and Authenticity in Interactive Simulation: Experimental Study %A Musa,Dahlia %A Gonzalez,Laura %A Penney,Heidi %A Daher,Salam %+ Department of Informatics, Ying Wu College of Computing, New Jersey Institute of Technology, University Heights, Newark, NJ, 07103, United States, 1 9735966848, salam.daher@njit.edu %K health care simulation %K interactivity %K remote learning %K video %K technology acceptance %K authenticity %K nursing education %K active learning %K passive learning %D 2023 %7 15.2.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Remote and virtual simulations have gained prevalence during the COVID-19 pandemic as institutions maintain social distancing measures. Because of the challenges of cost, flexibility, and feasibility in traditional mannequin simulation, many health care educators have used videos as a remote simulation modality; however, videos provide minimal interactivity. Objective: In this study, we aimed to evaluate the role of interactivity in students’ simulation experiences. We analyzed students’ perceptions of technology acceptance and authenticity in interactive and noninteractive simulations. Methods: Undergraduate nursing students participated in interactive and noninteractive simulations. The interactive simulation was conducted using interactive video simulation software that we developed, and the noninteractive simulation consisted of passively playing a video of the simulation. After each simulation, the students completed a 10-item technology acceptance questionnaire and 6-item authenticity questionnaire. The data were analyzed using the Wilcoxon signed-rank test. In addition, we performed an exploratory analysis to compare technology acceptance and authenticity in interactive local and remote simulations using the Mann-Whitney U test. Results: Data from 29 students were included in this study. Statistically significant differences were found between interactive and noninteractive simulations for overall technology acceptance (P<.001) and authenticity (P<.001). Analysis of the individual questionnaire items showed statistical significance for 3 out of the 10 technology acceptance items (P=.002, P=.002, and P=.004) and 5 out of the 6 authenticity items (P<.001, P<.001, P=.001, P=.003, and P=.005). The interactive simulation scored higher than the noninteractive simulation in all the statistically significant comparisons. Our exploratory analysis revealed that local simulation may promote greater perceptions of technology acceptance (P=.007) and authenticity (P=.027) than remote simulation. Conclusions: Students’ perceptions of technology acceptance and authenticity were greater in interactive simulation than in noninteractive simulation. These results support the importance of interactivity in students’ simulation experiences, especially in remote or virtual simulations in which students’ involvement may be less active. %M 36790842 %R 10.2196/40040 %U https://mededu.jmir.org/2023/1/e40040 %U https://doi.org/10.2196/40040 %U http://www.ncbi.nlm.nih.gov/pubmed/36790842 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43486 %T Optimizing the Implementation of Clinical Predictive Models to Minimize National Costs: Sepsis Case Study %A Rogers,Parker %A Boussina,Aaron E %A Shashikumar,Supreeth P %A Wardi,Gabriel %A Longhurst,Christopher A %A Nemati,Shamim %+ Department of Economics, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, United States, 1 405 850 4751, parogers@ucsd.edu %K sepsis %K machine learning %K evaluation %K utility assessment %K workflow simulation %K simulation %K model %K implementation %K data %K acute kidney injury %K injury %K technology %K care %K diagnosis %K clinical %K cost %D 2023 %7 13.2.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Sepsis costs and incidence vary dramatically across diagnostic categories, warranting a customized approach for implementing predictive models. Objective: The aim of this study was to optimize the parameters of a sepsis prediction model within distinct patient groups to minimize the excess cost of sepsis care and analyze the potential effect of factors contributing to end-user response to sepsis alerts on overall model utility. Methods: We calculated the excess costs of sepsis to the Centers for Medicare and Medicaid Services (CMS) by comparing patients with and without a secondary sepsis diagnosis but with the same primary diagnosis and baseline comorbidities. We optimized the parameters of a sepsis prediction algorithm across different diagnostic categories to minimize these excess costs. At the optima, we evaluated diagnostic odds ratios and analyzed the impact of compliance factors such as noncompliance, treatment efficacy, and tolerance for false alarms on the net benefit of triggering sepsis alerts. Results: Compliance factors significantly contributed to the net benefit of triggering a sepsis alert. However, a customized deployment policy can achieve a significantly higher diagnostic odds ratio and reduced costs of sepsis care. Implementing our optimization routine with powerful predictive models could result in US $4.6 billion in excess cost savings for CMS. Conclusions: We designed a framework for customizing sepsis alert protocols within different diagnostic categories to minimize excess costs and analyzed model performance as a function of false alarm tolerance and compliance with model recommendations. We provide a framework that CMS policymakers could use to recommend minimum adherence rates to the early recognition and appropriate care of sepsis that is sensitive to hospital department-level incidence rates and national excess costs. Customizing the implementation of clinical predictive models by accounting for various behavioral and economic factors may improve the practical benefit of predictive models. %M 36780203 %R 10.2196/43486 %U https://www.jmir.org/2023/1/e43486 %U https://doi.org/10.2196/43486 %U http://www.ncbi.nlm.nih.gov/pubmed/36780203 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40541 %T Advantages of a Training Course for Surgical Planning in Virtual Reality for Oral and Maxillofacial Surgery: Crossover Study %A Ulbrich,Max %A Van den Bosch,Vincent %A Bönsch,Andrea %A Gruber,Lennart Johannes %A Ooms,Mark %A Melchior,Claire %A Motmaen,Ila %A Wilpert,Caroline %A Rashad,Ashkan %A Kuhlen,Torsten Wolfgang %A Hölzle,Frank %A Puladi,Behrus %+ Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 88231, bpuladi@ukaachen.de %K virtual surgical planning %K virtual reality %K Elucis %K 3D Slicer %K oral and maxillofacial surgery %D 2023 %7 19.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: As an integral part of computer-assisted surgery, virtual surgical planning (VSP) leads to significantly better surgery results, such as for oral and maxillofacial reconstruction with microvascular grafts of the fibula or iliac crest. It is performed on a 2D computer desktop screen (DS) based on preoperative medical imaging. However, in this environment, VSP is associated with shortcomings, such as a time-consuming planning process and the requirement of a learning process. Therefore, a virtual reality (VR)–based VSP application has great potential to reduce or even overcome these shortcomings due to the benefits of visuospatial vision, bimanual interaction, and full immersion. However, the efficacy of such a VR environment has not yet been investigated. Objective: This study aimed to demonstrate the possible advantages of a VR environment through a substep of VSP, specifically the segmentation of the fibula (calf bone) and os coxae (hip bone), by conducting a training course in both DS and VR environments and comparing the results. Methods: During the training course, 6 novices were taught how to use a software application in a DS environment (3D Slicer) and in a VR environment (Elucis) for the segmentation of the fibula and os coxae, and they were asked to carry out the maneuvers as accurately and quickly as possible. Overall, 13 fibula and 13 os coxae were segmented for each participant in both methods (VR and DS), resulting in 156 different models (78 fibula and 78 os coxae) per method (VR and DS) and 312 models in total. The individual learning processes in both environments were compared using objective criteria (time and segmentation performance) and self-reported questionnaires. The models resulting from the segmentation were compared mathematically (Hausdorff distance and Dice coefficient) and evaluated by 2 experienced radiologists in a blinded manner. Results: A much faster learning curve was observed for the VR environment than the DS environment (β=.86 vs β=.25). This nearly doubled the segmentation speed (cm3/min) by the end of training, leading to a shorter time (P<.001) to reach a qualitative result. However, there was no qualitative difference between the models for VR and DS (P=.99). The VR environment was perceived by participants as more intuitive and less exhausting, and was favored over the DS environment. Conclusions: The more rapid learning process and the ability to work faster in the VR environment could save time and reduce the VSP workload, providing certain advantages over the DS environment. %M 36656632 %R 10.2196/40541 %U https://games.jmir.org/2023/1/e40541 %U https://doi.org/10.2196/40541 %U http://www.ncbi.nlm.nih.gov/pubmed/36656632 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38009 %T Teamwork Training With a Multiplayer Game in Health Care: Content Analysis of the Teamwork Principles Applied %A van Peppen,Lara %A Faber,Tjitske J E %A Erasmus,Vicki %A Dankbaar,Mary E W %+ Anesthesiologie, Pijn en Palliatieve Geneeskunde, Radboud Universitair Medisch Centrum, Huispost 717, Route 714, PO Box 9101, Nijmegen, 6500 HB, Netherlands, 31 243614406, Tjitske.Faber@radboudumc.nl %K teamwork %K skills training %K serious games %K multiplayer game %K medical students %K content-analysis %K health care %K interprofessional teamwork %D 2022 %7 9.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In health care, teamwork skills are critical for patient safety; therefore, great emphasis is placed on training these skills. Given that training is increasingly designed in a blended way, serious games may offer an efficient method of preparing face-to-face simulation training of these procedural skills. Objective: This study aimed to investigate the teamwork principles that were used during gameplay by medical students and teamwork experts. Findings can improve our understanding of the potential of serious games for training these complex skills. Methods: We investigated a web-based multiplayer game designed for training students’ interprofessional teamwork skills. During gameplay, 4 players in different roles (physician, nurse, medical student, and student nurse) had to share information, prioritize tasks, and decide on next steps to take in web-based patient scenarios, using one-to-one and team chats. We performed a qualitative study (content analysis) on these chats with 144 fifth-year medical students and 24 health care teamwork experts (as a benchmark study) playing the game in groups of 4. Game chat data from 2 scenarios were analyzed. For the analysis, a deductive approach was used, starting with a conceptual framework based on Crew Resource Management principles, including shared situational awareness, decision-making, communication, team management, and debriefing. Results: Results showed that most teamwork principles were used during gameplay: shared situational awareness, decision-making (eg, re-evaluation), communication (eg, closed loop), and team management (eg, distributing the workload). Among students, these principles were often used on a basic level. Among experts, teamwork principles were used with more open forms of speak up and more justification of decisions. Some specific Crew Resource Management principles were less observed among both groups, for example, prevention of fixation errors and use of cognitive aids. Both groups showed relatively superficial debriefing reflections. Conclusions: Playing a multiplayer game for interprofessional teamwork appears to facilitate the application of teamwork principles by students in all important teamwork domains on a basic level. Expert players applied similar teamwork principles on a moderately high complexity level. Some teamwork principles were less observed among both students and expert groups, probably owing to the artifacts of the game environment (eg, chatting instead of talking). A multiplayer game for teamwork training can elicit the application of important, basic teamwork principles, both among novices and experts, and provides them with a flexible, accessible, and engaging learning environment. This may create time for exercising more complex skills during face-to-face training. %M 36485016 %R 10.2196/38009 %U https://games.jmir.org/2022/4/e38009 %U https://doi.org/10.2196/38009 %U http://www.ncbi.nlm.nih.gov/pubmed/36485016 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e41097 %T An Automated Virtual Reality Training System for Teacher-Student Interaction: A Randomized Controlled Trial %A King,Seth %A Boyer,Joseph %A Bell,Tyler %A Estapa,Anne %+ Department of Teaching and Learning, College of Education, University of Iowa, 240 S. Madison St., Iowa City, IA, 52242, United States, 1 828 448 0950, sakng@uiowa.edu %K virtual reality %K artificial intelligence %K behavioral skills training %K education %K professional development %K staff training %K mathematics %D 2022 %7 8.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Shortages in qualified supervision and other resources prevent education personnel from rehearsing effective practices. Interactive simulations, although increasingly used in education, frequently require instructor management. Automated simulations rarely engage trainees in skills related to practice (eg, speech). Objective: We evaluated the capability of delivering behavioral skills training through an automated virtual reality (VR) simulation using artificial intelligence to improve the implementation of a nondirective mathematical questioning strategy. Methods: We recruited and randomly assigned 30 college-aged participants to equivalent treatment (ie, lecture, modeling, and VR; 15/30, 50%) and control groups (ie, lecture and modeling only; 15/30, 50%). The participants were blind to treatment conditions. Sessions and assessments were conducted face to face and involved the use of VR for assessment regardless of the condition. Lessons concerned the use of a nondirective mathematical questioning strategy in instances where a simulated student provided correct or incorrect answers to word problems. The measures included observed and automated assessments of participant performance and subjective assessments of participant confidence. The participants completed the pretest, posttest, and maintenance probes each week over the course of 3 weeks. Results: A mixed ANOVA revealed significant main effects of time (F2,27=124.154; P<.001; ηp2=0.816) and treatment (F1,28=19.281; P<.001; ηp2=0.408) as well as an interaction effect (F2,28=8.429; P<.001; ηp2=0.231) for the average percentage of steps in the questioning procedure. Posttest scores for the intervention group (mean 88%, SD 22.62%) exceeded those of the control group (mean 63.33%, SD 22.64%), with t28=3.653, P<.001, and Cohen d=1.334. Maintenance scores indicated a positive effect of the intervention (mean 83.33%, SD 24.40%) relative to the control (mean 54.67%, SD 15.98%), t28=3.807, P<.001, Cohen d=1.39. A Mann-Whitney U test indicated that the treatment groups’ self-ratings of confidence (mean 2.41, SD 0.51) were higher than those of the control group (mean 2.04, SD 0.52), U=64, P=.04, r=0.137. Conclusions: The results demonstrate the potential of artificial intelligence-augmented VR to deliver effective, evidence-based training with limited instructor management. Additional work is needed to demonstrate the cascading effect of training on authentic practice and to encompass a wider range of skills. %M 36480248 %R 10.2196/41097 %U https://games.jmir.org/2022/4/e41097 %U https://doi.org/10.2196/41097 %U http://www.ncbi.nlm.nih.gov/pubmed/36480248 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e40727 %T A Novel Scenario-Based, Mixed-Reality Platform for Training Nontechnical Skills of Battlefield First Aid: Prospective Interventional Study %A Du,Wenqiong %A Zhong,Xin %A Jia,Yijun %A Jiang,Renqing %A Yang,Haoyang %A Ye,Zhao %A Zong,Zhaowen %+ State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, 30 Gaotanyan St, Shapingba District, Chongqing, 400038, China, 86 138 8350 6677, zongzhaowen@163.com %K mixed reality %K decision-making %K team work %K battlefield first aid %K nontechnical skills %K training %K next-generation modeling %K virtual reality %K medical education %D 2022 %7 6.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although battlefield first aid (BFA) training shares many common features with civilian training, such as the need to address technical skills and nontechnical skills (NTSs), it is more highly scenario-dependent. Studies into extended reality show clear benefits in medical training; however, the training effects of extended reality on NTSs, including teamwork and decision-making in BFA, have not been fully proven. Objective: The current study aimed to create and test a scenario-based, mixed-reality platform suitable for training NTSs in BFA. Methods: First, using next-generation modeling technology and an animation synchronization system, a 10-person offensive battle drill was established. Decision-making training software addressing basic principles of tactical combat casualty care was constructed and integrated into the scenarios with Unreal Engine 4 (Epic Games). Large-space teamwork and virtual interaction systems that made sense in the proposed platform were developed. Unreal Engine 4 and software engineering technology were used to combine modules to establish a mixed-reality BFA training platform. A total of 20 Grade 4 medical students were recruited to accept BFA training with the platform. Pretraining and posttraining tests were carried out in 2 forms to evaluate the training effectiveness: one was knowledge acquisition regarding the NTS and the other was a real-world, scenario-based test. In addition, the students were asked to rate their agreement with a series of survey items on a 5-point Likert scale. Results: A battlefield geographic environment, tactical scenarios, scenario-based decision software, large-space teamwork, and virtual interaction system modules were successfully developed and combined to establish the mixed-reality training platform for BFA. The posttraining score of the students’ knowledge acquisition was significantly higher than that of pretraining (t=−12.114; P≤.001). Furthermore, the NTS score and the total score that the students obtained in the real-world test were significantly higher than those before training (t=−17.756 and t=−21.354, respectively; P≤.001). However, there was no significant difference between the scores of technical skills that the students obtained before and after training. A posttraining survey revealed that the students found the platform helpful in improving NTSs for BFA, and they were confident in applying BFA skills after training. However, most trainees thought that the platform was not helpful for improving the technical skills of BFA, and 45% (9/20) of the trainees were not satisfied with the simulation effect. Conclusions: A scenario-based, mixed-reality platform was constructed in this study. In this platform, interaction of the movement of multiple players in a large space and the interaction of decision-making by the trainees between the real world and the virtual world were accomplished. The platform could improve the NTSs of BFA. Future works, including improvement of the simulation effects and development of a training platform that could effectively improve both the technical skills and NTSs of BFA, will be carried out. %M 36472903 %R 10.2196/40727 %U https://games.jmir.org/2022/4/e40727 %U https://doi.org/10.2196/40727 %U http://www.ncbi.nlm.nih.gov/pubmed/36472903 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 4 %P e35712 %T Software-Based Simulation on a 3D Environment for Vaccination Teaching and Learning: Design Science Research %A Domingueti,Daniel %A Barbosa Feres Carvalho,Darlinton %A Colombo Dias,Diego Roberto %A Oliveira,Valéria Conceição %+ Departamento de Ciência da Computação, Universidade Federal de São João del-Rei, Campus Tancredo Neves, BR-494, s/n, Sao Joao del Rei, 36301-360, Brazil, 55 32 3379 4935, darlinton@acm.org %K software simulation %K vaccination room %K immunization %K teaching %K training %K evaluation %K virtual world %K Unity3D %K SUS %K UTAUT2 %D 2022 %7 2.12.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Student training requires specific laboratories for vaccination practice, which are usually limited, and even professionals’ continuing education regularly lacks proper care. Thus, new methodologies, concepts, and technologies, such as software-based simulations, are in highly demand. Objective: This work aims to develop a 3D virtual environment to support teaching activities in the vaccination room. The software-based simulation must contribute positively to teaching considering a variable set of scenarios. Methods: We applied the design science research method to guide the work. First, the concepts and opportunities were raised, which we used to build the simulation (ie, the proposed technological artifact). The development was assisted by a specialist, in which we sought to create a vaccination room according to Brazilian standards. The artifact evaluation was achieved in 2 stages: (1) an evaluation to validate the design with experts through the Delphi method; and (2) a field evaluation with nursing students to validate aspects of usability (System Usability Scale [SUS]) and technology acceptance and use (Unified Theory of Acceptance and Use of Technology version 2). Results: We built the simulation software using the Unity game engine. An additional module was also developed to create simulation scenarios and view the students’ performance reports. The design evaluation showed that the proposed solution is adequate. Students’ evaluations confirm good usability (SUS score of 81.4), besides highlighting Performance Expectation as the most positively influential factor of Behavioral Intention. Effort Expectancy is positively affected by younger users. Both evaluation audiences cited the high relevance of the proposed artifact for teaching. Points for improvement are also reported. Conclusions: The research accomplished its goal of creating a software-based simulation to support teaching scenarios in the vaccination room. The evaluations still reveal desirable improvements and user behavior toward this kind of technological artifact. %M 36459390 %R 10.2196/35712 %U https://mededu.jmir.org/2022/4/e35712 %U https://doi.org/10.2196/35712 %U http://www.ncbi.nlm.nih.gov/pubmed/36459390 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36079 %T Preliminary User Evaluation of a New Dental Technology Virtual Simulation System: Development and Validation Study %A Pang,Mengwei %A Zhao,Xiaohan %A Lu,Daiyu %A Dong,Yihan %A Jiang,Lin %A Li,Jie %A Ji,Ping %+ College of Stomatology, Chongqing Medical University, 426# Songshibei Road, Yubei District, Chongqing, 401147, China, 86 023 8886 0026, jiping@hospital.cqmu.edu.cn %K virtual simulation %K dental technology %K OSCE %K virtual reality %K dentistry %K dental technician %K framework %K certified dental technician %K development %K validation %K serious game %K dental technology %K dental %K technology %D 2022 %7 12.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: With the advancements in the dental health care industry, the demand for dental technicians has increased. Dental technicians should be thoroughly assessed and trained in practical skills and pass professional certification examinations to ensure that they are competent to work closely with dentists. Unfortunately, such training courses and tests are in short supply worldwide. The use of virtual simulation technology can help solve these problems. Objective: This study presents a new strategic framework design for a certified dental technician practical examination called as the certified Objective Manipulative Skill Examination of Dental Technicians (OMEDT), which is based on the Objective Structured Clinical Examination (OSCE). We present the development and validation of the OMEDT system, a new virtual simulated training system, to meet the demands of the OMEDT framework. The combination of OMEDT and the OMEDT system can solve the complex problems encountered in the certified dental technician practical examination with excellent efficiency, high quality, and low cost. Methods: The OMEDT framework design was constructed according to the OSCE guide and the Chinese vocational skill standards for dental technicians. To develop the OMEDT system, we organized a new framework based on the virtual learning network platform, the haptic feedback system, and the real-time dental training and evaluation system. The effectiveness evaluation of the OMEDT system was divided into 2 phases: in the first phase, 36 students were recruited to use the test module to finish the task and their performance data were collected and analyzed; and in the second phase, a questionnaire was administered to 30 students who used the system for their studies and graduation exams. Results: The OMEDT and the corresponding skill training virtual simulation OMEDT system were developed, and preliminary user evaluation was performed to assess their effectiveness and usefulness. The OMEDT system was found to improve students’ practical skills by training with the evaluation results. In addition, several key research topics were explored, including the effects of positive feedback of the knowledge of results on the improvement of the students’ skill level and the common sense transformation of educators in the virtual simulation technology environment. Conclusions: The development of OMEDT and the OMEDT system has been completed and their effectiveness has been verified. %M 36094803 %R 10.2196/36079 %U https://games.jmir.org/2022/3/e36079 %U https://doi.org/10.2196/36079 %U http://www.ncbi.nlm.nih.gov/pubmed/36094803 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38669 %T Designing Virtual Reality–Based Conversational Agents to Train Clinicians in Verbal De-escalation Skills: Exploratory Usability Study %A Moore,Nathan %A Ahmadpour,Naseem %A Brown,Martin %A Poronnik,Philip %A Davids,Jennifer %+ Digital Health Solutions, Western Sydney Local Health District, Cumberland Hospital East Campus, Building 106, North Parramatta, 2151, Australia, 61 0427850889, nathan.moore@health.nsw.gov.au %K virtual reality %K code black %K verbal de-escalation %K violence and aggression %K education %K clinical training %K conversational agent %D 2022 %7 6.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Violence and aggression are significant workplace challenges faced by clinicians worldwide. Traditional methods of training consist of “on-the-job learning” and role-play simulations. Although both approaches can result in improved skill levels, they are not without limitation. Interactive simulations using virtual reality (VR) can complement traditional training processes as a cost-effective, engaging, easily accessible, and flexible training tool. Objective: In this exploratory study, we aimed to determine the feasibility of and barriers to verbal engagement with a virtual agent in the context of the Code Black VR application. Code Black VR is a new interactive VR-based verbal de-escalation trainer that we developed based on the Clinical Training Through VR Design Framework. Methods: In total, 28 participants with varying clinical expertise from 4 local hospitals enrolled in the Western Sydney Local Health District Clinical Initiative Nurse program and Transition to Emergency Nursing Programs and participated in 1 of 5 workshops. They completed multiple playthroughs of the Code Black VR verbal de-escalation trainer application and verbally interacted with a virtual agent. We documented observations and poststudy reflection notes. After the playthroughs, the users completed the System Usability Scale and provided written comments on their experience. A thematic analysis was conducted on the results. Data were also obtained through the application itself, which also recorded the total interactions and successfully completed interactions. Results: The Code Black VR verbal de-escalation training application was well received. The findings reinforced the factors in the existing design framework and identified 3 new factors—motion sickness, perceived value, and privacy—to be considered for future application development. Conclusions: Verbal interaction with a virtual agent is feasible for training staff in verbal de-escalation skills. It is an effective medium to supplement clinician training in verbal de-escalation skills. We provide broader design considerations to guide further developments in this area. %M 35793129 %R 10.2196/38669 %U https://games.jmir.org/2022/3/e38669 %U https://doi.org/10.2196/38669 %U http://www.ncbi.nlm.nih.gov/pubmed/35793129 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e38952 %T Instructor Development Workshops for Advanced Life Support Training Courses Held in a Fully Virtual Space: Observational Study %A Kiyozumi,Tetsuro %A Ishigami,Norio %A Tatsushima,Daisuke %A Araki,Yoshiyuki %A Yoshimura,Yuya %A Saitoh,Daizoh %+ Department of Defense Medicine, National Defense Medical College, Namiki 3-2, Tokorozawa, 3598513, Japan, 81 429951211, kiyosan@ka2.so-net.ne.jp %K virtual reality %K virtual space %K instructor development workshop %K resuscitation training course %K advanced life support %K resuscitation training %K digital training %K virtual learning %K digital education %K medical education %D 2022 %7 29.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Various face-to-face training opportunities have been lost due to the COVID-19 pandemic. Instructor development workshops for advanced resuscitation (ie, advanced life support) training courses are no exception. Virtual reality (VR) is an attractive strategy for remote training. However, to our knowledge, there are no reports of resuscitation instructor training programs being held in a virtual space. Objective: This study aimed to investigate the learning effects of an instructor development workshop that was conducted in a virtual space. Methods: In this observational study, we created a virtual workshop space by using NEUTRANS (Synamon Inc)—a commercial VR collaboration service. The instructor development workshop for the advanced life support training course was held in a virtual space (ie, termed the VR course) as a certified workshop by the Japanese Association of Acute Medicine. We asked 13 instructor candidates (students) who participated in the VR course to provide a workshop report (VR group). Reports from a previously held face-to-face workshop (ie, the face-to-face course and group) were likewise prepared for comparison. A total of 5 certified instructor trainers viewed and scored the reports on a 5-point Likert scale. Results: All students completed the VR course without any problems and received certificates of completion. The scores for the VR group and the face-to-face group did not differ at the level of statistical significance (median 3.8, IQR 3.8-4.0 and median 4.2, IQR 3.9-4.2, respectively; P=.41). Conclusions: We successfully conducted an instructor development workshop in a virtual space. The degree of learning in the virtual workshop was the same as that in the face-to-face workshop. %M 35767318 %R 10.2196/38952 %U https://games.jmir.org/2022/2/e38952 %U https://doi.org/10.2196/38952 %U http://www.ncbi.nlm.nih.gov/pubmed/35767318 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 2 %P e34791 %T Freestyle Deliberate Practice Cadaveric Hand Surgery Simulation Training for Orthopedic Residents: Cohort Study %A James,Hannah K %A Fawdington,Ross A %+ Clinical Trials Unit, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, United Kingdom, 44 02476574880, hsmith22@doctors.org.uk %K simulation %K high fidelity simulation %K orthopedic residency %K surgical training %K postgraduate education %K medical education %K medical student %K surgeon %K hand %K hand surgery %K surgery %K orthopedic %K cadaver %K cadaveric simulation %K cadaveric %K training %K cadaveric training %K DP %K deliberate practice %D 2022 %7 29.6.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Cadaveric simulation training may be part of the solution to reduced quantity and quality of operative surgical training in the modern climate. Cadaveric simulation allows the early part of the surgical learning curve to be moved away from patients into the laboratory, and there is a growing body of evidence that it may be an effective adjunct to traditional methods for training surgical residents. It is typically resource constrained as cadaveric material and facilities are expensive. Therefore, there is a need to be sure that any given cadaveric training intervention is maximally impactful. Deliberate practice (DP) theory as applied to cadaveric simulation training might enhance the educational impact. Objective: The objectives of this study were (1) to assess the impact of a freestyle DP cadaveric hand surgery simulation training intervention on self-reported operative confidence for 3 different procedures and (2) to assess the subjective transfer validity, perceived educational value, and simulation fidelity of the training. Methods: This study used validated questionnaires to assess the training impact on a cohort of orthopedic residents. The freestyle course structure allowed the residents to prospectively define personalized learning objectives, which were then addressed through DP. The study was conducted at Keele Anatomy and Surgical Training Centre, a medical school with an integrated cadaveric training laboratory in England, United Kingdom. A total of 22 orthopedic surgery residents of postgraduate year (PGY) 5-10 from 3 regional surgical training programs participated in this study. Results: The most junior (PGY 5-6) residents had the greatest self-reported confidence gains after training for the 3 procedures (distal radius open reduction internal fixation, flexor tendon repair, ulnar shortening osteotomy), and these gains diminished with resident seniority. The confidence gains were proportional to the perceived procedural complexity, with the most complex procedure having the lowest pretraining confidence score across all experience levels, and the greatest confidence increase in posttraining. Midstage (PGY 7-8) residents reported receiving the highest level of educational benefit from the training but perceived the simulation to be less realistic, compared to either the junior or senior residents. The most senior residents (PGY 9-10) reported the greatest satisfaction with the self-directed, freestyle nature of the training. All groups reported that they were extremely likely to transfer their technical skill gains to their workplace, that they would change their current practice based on these skills, and that their patients would benefit as a result of their having undertaken the training. Conclusions: Freestyle, resident-directed cadaveric simulation provides optimum DP conditions whereby residents can target their individualized learning needs. By receiving intensive, directed feedback from faculty, they can make rapid skill gains in a short amount of time. Subjective transfer validity potential from the training was very high, and objective, quantitative evidence of this is required from future work. %M 35767315 %R 10.2196/34791 %U https://mededu.jmir.org/2022/2/e34791 %U https://doi.org/10.2196/34791 %U http://www.ncbi.nlm.nih.gov/pubmed/35767315 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 2 %P e33565 %T An Alternative to Traditional Bedside Teaching During COVID-19: High-Fidelity Simulation-Based Study %A Ajab,Shereen %A Pearson,Emma %A Dumont,Steven %A Mitchell,Alicia %A Kastelik,Jack %A Balaji,Packianathaswamy %A Hepburn,David %+ Hull York Medical School, Hull University Teaching Hospitals NHS Trust, Allam Medical Building, Cottingham Road, Hull, HU6 7RX, United Kingdom, 44 1482875875, shereen.ajab@nhs.net %K simulation %K high fidelity %K low fidelity %K COVID-19 %K bedside teaching %K undergraduate medical education %K fidelity %K medical education %K medical student %K review %K innovation %K risk %K design %K implementation %D 2022 %7 9.5.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Bedside teaching is integral to medical education and has been highlighted to improve clinical and communication skills, as well as clinical reasoning. Despite the significant advantages of bedside teaching, its usage within medical education has been declining, and COVID-19 has added additional challenges. The pandemic has resulted in a significant reduction in opportunities to deliver bedside teaching due to risk of viral exposure, patients declining student interactions, and ward closures. Educators have therefore been required to be innovative in their teaching methods, leading to the use of online learning, social media platforms, and simulation. Simulation-based education allows for learning in a low-risk environment and affords the opportunity for deliberated repeated practice with case standardization. The results demonstrate that simulation-based training can increase students’ confidence, increase the rates of correct clinical diagnoses, and improve retention of skills and knowledge when compared with traditional teaching methods. Objective: To mitigate the impact of COVID-19 upon bedside teaching for third year students at Hull York Medical School amid closure of the cardiorespiratory wards, a high-fidelity simulation-based model of traditional bedside teaching was designed and implemented. The objectives of the teaching session were to enable students to perform history taking and a focused cardiorespiratory clinical examination in a COVID-19–safe environment using SimMan 3G. Methods: Four clinical teaching fellows with experience of simulation-based medical education scripted histories for 2 common cardiorespiratory cases, which were asthma and aortic stenosis. The simulation sessions were designed for students to take a focused cardiorespiratory history and clinical examination using SimMan 3G. All cases involved dynamic vital signs, and the simulator allowed for auscultation of an ejection systolic murmur and wheezing in accordance with the cases chosen. Key aspects of the pathologies, including epidemiology, differential diagnoses, investigations, and management, were summarized using an interactive PowerPoint presentation, followed by a debriefing session. Results: In total, 12 third year medical students undertook the sessions, and overall feedback was highly positive. Of the 10 students who completed the feedback questionnaires, 90% (n=9) felt more confident in their clinical examination skills following the teaching; 100% (n=10) of the students responded that they would recommend the session to a colleague; and implementation of regular simulation was frequently requested on feedback. These results are in keeping with the current literature. Conclusions: Bedside teaching continues to face ongoing challenges from the COVID-19 pandemic as well as declining patient recruitment and fluctuations in clinical findings. The support for simulation-based medical education is derived from high-quality studies; however, studies describing the use of this technology for bedside teaching in the undergraduate curriculum are limited. The authors describe a highly effective teaching session amid the pandemic, which allowed for maintenance of staff and student safety alongside continued education during a challenging time for educators globally. %M 35404828 %R 10.2196/33565 %U https://mededu.jmir.org/2022/2/e33565 %U https://doi.org/10.2196/33565 %U http://www.ncbi.nlm.nih.gov/pubmed/35404828 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 2 %P e32657 %T Perspectives of 360-Degree Cinematic Virtual Reality: Interview Study Among Health Care Professionals %A Beverly,Elizabeth %A Rigot,Brooke %A Love,Carrie %A Love,Matt %+ Ohio University Heritage College of Osteopathic Medicine, 1 Ohio University, Irvine Hall 307, Athens, OH, 45701, United States, 1 740 593 4616, beverle1@ohio.edu %K virtual reality %K qualitative %K medical education %K health care %K digital learning %K learning platform %K health care providers %D 2022 %7 29.4.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: The global market for medical education is projected to increase exponentially over the next 5 years. A mode of delivery expected to drive the growth of this market is virtual reality (VR). VR simulates real-world objects, events, locations, and interactions in 3D multimedia sensory environments. It has been used successfully in medical education for surgical training, learning anatomy, and advancing drug discovery. New VR research has been used to simulate role-playing and clinical encounters; however, most of this research has been conducted with health professions students and not current health care professionals. Thus, more research is needed to explore how health care professionals experience VR with role-playing and clinical encounters. Objective: The aim of this study was to explore health care professionals’ experiences with a cinematic VR (cine-VR) training program focused on role-playing and clinical encounters addressing social determinants of health, Appalachian culture, and diabetes. Cine-VR leverages 360-degree video with the narrative storytelling of cinema to create an engaging educational experience. Methods: We conducted in-depth telephone interviews with health care professionals who participated in the cine-VR training. The interviews were audio recorded and transcribed verbatim. A multidisciplinary team coded and analyzed the data using content and thematic analyses with NVivo software. Results: We conducted 24 in-depth interviews with health care professionals (age=45.3, SD 11.3, years; n=16, 67%, women; n=22, 92%, White; and n=4, 17%, physicians) to explore their experiences with the cine-VR training. Qualitative analysis revealed five themes: immersed in the virtual world: seeing a 360-degree sphere allowed participants to immerse themselves in the virtual world; facilitated knowledge acquisition: all the participants accurately recalled the culture of Appalachia and listed the social determinants of health presented in the training; empathized with multiple perspectives: the cine-VR provided a glimpse into the real life of the main character, and participants described thinking about, feeling, and empathizing with the character’s frustrations and disappointments; perceived ease of use of cine-VR: 96% (23/24) of the participants described the cine-VR as easy to use, and they liked the 360-degree movement, image resolution, and sound quality but noted limitations with the buttons on the headsets and risk for motion sickness; and perceived utility of cine-VR as a teaching tool: participants described cine-VR as an effective teaching tool because it activated visual and affective learning for them. Conclusions: Participants emphasized the realism of the cine-VR training program. They attributed the utility of the cine-VR to visual learning in conjunction with the emotional connection to the VR characters. Furthermore, participants reported that the cine-VR increased their empathy for people. More research is needed to confirm an association between the level of immersion and empathy in cine-VR training for health care professionals. %M 35486427 %R 10.2196/32657 %U https://mededu.jmir.org/2022/2/e32657 %U https://doi.org/10.2196/32657 %U http://www.ncbi.nlm.nih.gov/pubmed/35486427 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 2 %P e30988 %T Video-Based Communication Assessment of Physician Error Disclosure Skills by Crowdsourced Laypeople and Patient Advocates Who Experienced Medical Harm: Reliability Assessment With Generalizability Theory %A White,Andrew A %A King,Ann M %A D’Addario,Angelo E %A Brigham,Karen Berg %A Dintzis,Suzanne %A Fay,Emily E %A Gallagher,Thomas H %A Mazor,Kathleen M %+ Department of Medicine, University of Washington School of Medicine, Box 356429, 1959 Pacific St, Seattle, WA, 98195, United States, 1 206 616 1447, andwhite@uw.edu %K medical error disclosure %K simulation studies %K communication assessment %K graduate medical education %K crowdsourcing %K patient-centered care %K generalizability theory %K medical education %K medical error %K communication %D 2022 %7 29.4.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Residents may benefit from simulated practice with personalized feedback to prepare for high-stakes disclosure conversations with patients after harmful errors and to meet American Council on Graduate Medical Education mandates. Ideally, feedback would come from patients who have experienced communication after medical harm, but medical researchers and leaders have found it difficult to reach this community, which has made this approach impractical at scale. The Video-Based Communication Assessment app is designed to engage crowdsourced laypeople to rate physician communication skills but has not been evaluated for use with medical harm scenarios. Objective: We aimed to compare the reliability of 2 assessment groups (crowdsourced laypeople and patient advocates) in rating physician error disclosure communication skills using the Video-Based Communication Assessment app. Methods: Internal medicine residents used the Video-Based Communication Assessment app; the case, which consisted of 3 sequential vignettes, depicted a delayed diagnosis of breast cancer. Panels of patient advocates who have experienced harmful medical error, either personally or through a family member, and crowdsourced laypeople used a 5-point scale to rate the residents’ error disclosure communication skills (6 items) based on audiorecorded responses. Ratings were aggregated across items and vignettes to create a numerical communication score for each physician. We used analysis of variance, to compare stringency, and Pearson correlation between patient advocates and laypeople, to identify whether rank order would be preserved between groups. We used generalizability theory to examine the difference in assessment reliability between patient advocates and laypeople. Results: Internal medicine residents (n=20) used the Video-Based Communication Assessment app. All patient advocates (n=8) and 42 of 59 crowdsourced laypeople who had been recruited provided complete, high-quality ratings. Patient advocates rated communication more stringently than crowdsourced laypeople (patient advocates: mean 3.19, SD 0.55; laypeople: mean 3.55, SD 0.40; P<.001), but patient advocates’ and crowdsourced laypeople’s ratings of physicians were highly correlated (r=0.82, P<.001). Reliability for 8 raters and 6 vignettes was acceptable (patient advocates: G coefficient 0.82; crowdsourced laypeople: G coefficient 0.65). Decision studies estimated that 12 crowdsourced layperson raters and 9 vignettes would yield an acceptable G coefficient of 0.75. Conclusions: Crowdsourced laypeople may represent a sustainable source of reliable assessments of physician error disclosure skills. For a simulated case involving delayed diagnosis of breast cancer, laypeople correctly identified high and low performers. However, at least 12 raters and 9 vignettes are required to ensure adequate reliability and future studies are warranted. Crowdsourced laypeople rate less stringently than raters who have experienced harm. Future research should examine the value of the Video-Based Communication Assessment app for formative assessment, summative assessment, and just-in-time coaching of error disclosure communication skills. %M 35486423 %R 10.2196/30988 %U https://mededu.jmir.org/2022/2/e30988 %U https://doi.org/10.2196/30988 %U http://www.ncbi.nlm.nih.gov/pubmed/35486423 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e31464 %T Overcoming Decisional Gaps in High-Risk Prescribing by Junior Physicians Using Simulation-Based Training: Protocol for a Randomized Controlled Trial %A Lauffenburger,Julie C %A DiFrancesco,Matthew F %A Barlev,Renee A %A Robertson,Ted %A Kim,Erin %A Coll,Maxwell D %A Haff,Nancy %A Fontanet,Constance P %A Hanken,Kaitlin %A Oran,Rebecca %A Avorn,Jerry %A Choudhry,Niteesh K %+ Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street Suite 3030, Boston, MA, 02120, United States, 1 6175258865, jlauffenburger@bwh.harvard.edu %K pragmatic trial %K behavioral science %K prescribing %K benzodiazepines %K antipsychotics %K impact evaluation %D 2022 %7 27.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Gaps between rational thought and actual decisions are increasingly recognized as a reason why people make suboptimal choices in states of heightened emotion, such as stress. These observations may help explain why high-risk medications continue to be prescribed to acutely ill hospitalized older adults despite widely accepted recommendations against these practices. Role playing and other efforts, such as simulation training, have demonstrated benefits to help people avoid decisional gaps but have not been tested to reduce overprescribing of high-risk medications. Objective: This study aims to evaluate the impact of a simulation-based training program designed to address decisional gaps on prescribing of high-risk medications compared with control. Methods: In this 2-arm pragmatic trial, we are randomizing at least 36 first-year medical resident physicians (ie, interns) who provide care on inpatient general medicine services at a large academic medical center to either intervention (simulation-based training) or control (online educational training). The intervention comprises a 40-minute immersive individual simulation training consisting of a reality-based patient care scenario in a simulated environment at the beginning of their inpatient service rotation. The simulation focuses on 3 types of high-risk medications, including benzodiazepines, antipsychotics, and sedative hypnotics (Z-drugs), in older adults, and is specifically designed to help the physicians identify their reactions and prescribing decisions in stressful situations that are common in the inpatient setting. The simulation scenario is followed by a semistructured debriefing with an expert facilitator. The trial’s primary outcome is the number of medication doses for any of the high-risk medications prescribed by the interns to patients aged 65 years or older who were not taking one of the medications upon admission. Secondary outcomes include prescribing by all providers on the care team, being discharged on 1 of the medications, and prescribing of related medications (eg, melatonin, trazodone), or the medications of interest for the control intervention. These outcomes will be measured using electronic health record data. Results: Recruitment of interns began on March 29, 2021. Recruitment for the trial ended in Q42021, with follow-up completed by Q12022. Conclusions: This trial will evaluate the impact of a simulation-based training program designed using behavioral science principles on prescribing of high-risk medications by junior physicians. If the intervention is shown to be effective, this approach could potentially be reproducible by others and for a broader set of behaviors. Trial Registration: ClinicalTrials.gov NCT04668248; https://clinicaltrials.gov/ct2/show/NCT04668248 International Registered Report Identifier (IRRID): PRR1-10.2196/31464 %M 35475982 %R 10.2196/31464 %U https://www.researchprotocols.org/2022/4/e31464 %U https://doi.org/10.2196/31464 %U http://www.ncbi.nlm.nih.gov/pubmed/35475982 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34781 %T Augmented Reality-Based Surgery on the Human Cadaver Using a New Generation of Optical Head-Mounted Displays: Development and Feasibility Study %A Puladi,Behrus %A Ooms,Mark %A Bellgardt,Martin %A Cesov,Mark %A Lipprandt,Myriam %A Raith,Stefan %A Peters,Florian %A Möhlhenrich,Stephan Christian %A Prescher,Andreas %A Hölzle,Frank %A Kuhlen,Torsten Wolfgang %A Modabber,Ali %+ Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 88231, bpuladi@ukaachen.de %K digital health in surgery %K surgical technique %K surgical training %K computer-assisted surgery %K optical see-through head-mounted display %K HoloLens %K surgical navigation %K medical regulation %K open-source %K AR %K augmented reality %K surgery %K surgeon %K cadaver %K serious game %K head-mounted display %D 2022 %7 25.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although nearly one-third of the world’s disease burden requires surgical care, only a small proportion of digital health applications are directly used in the surgical field. In the coming decades, the application of augmented reality (AR) with a new generation of optical-see-through head-mounted displays (OST-HMDs) like the HoloLens (Microsoft Corp) has the potential to bring digital health into the surgical field. However, for the application to be performed on a living person, proof of performance must first be provided due to regulatory requirements. In this regard, cadaver studies could provide initial evidence. Objective: The goal of the research was to develop an open-source system for AR-based surgery on human cadavers using freely available technologies. Methods: We tested our system using an easy-to-understand scenario in which fractured zygomatic arches of the face had to be repositioned with visual and auditory feedback to the investigators using a HoloLens. Results were verified with postoperative imaging and assessed in a blinded fashion by 2 investigators. The developed system and scenario were qualitatively evaluated by consensus interview and individual questionnaires. Results: The development and implementation of our system was feasible and could be realized in the course of a cadaver study. The AR system was found helpful by the investigators for spatial perception in addition to the combination of visual as well as auditory feedback. The surgical end point could be determined metrically as well as by assessment. Conclusions: The development and application of an AR-based surgical system using freely available technologies to perform OST-HMD–guided surgical procedures in cadavers is feasible. Cadaver studies are suitable for OST-HMD–guided interventions to measure a surgical end point and provide an initial data foundation for future clinical trials. The availability of free systems for researchers could be helpful for a possible translation process from digital health to AR-based surgery using OST-HMDs in the operating theater via cadaver studies. %M 35468090 %R 10.2196/34781 %U https://games.jmir.org/2022/2/e34781 %U https://doi.org/10.2196/34781 %U http://www.ncbi.nlm.nih.gov/pubmed/35468090 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e35058 %T The Effect of a Sepsis Interprofessional Education Using Virtual Patient Telesimulation on Sepsis Team Care in Clinical Practice: Mixed Methods Study %A Chua,Wei Ling %A Ooi,Sim Leng %A Chan,Gene Wai Han %A Lau,Tang Ching %A Liaw,Sok Ying %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Level 3, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore, 117597, Singapore, 65 6516 7449, chuaweiling@nus.edu.sg %K sepsis %K interprofessional education %K team training %K nurse-physician communication %K simulation %K telesimulation %D 2022 %7 18.4.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Improving interprofessional communication and collaboration is necessary to facilitate the early identification and treatment of patients with sepsis. Preparing undergraduate medical and nursing students for the knowledge and skills required to assess, escalate, and manage patients with sepsis is crucial for their entry into clinical practice. However, the COVID-19 pandemic and social distancing measures have created the need for interactive distance learning to support collaborative learning. Objective: This study aimed to evaluate the effect of sepsis interprofessional education on medical and nursing students’ sepsis knowledge, team communication skills, and skill use in clinical practice. Methods: A mixed methods design using a 1-group pretest-posttest design and focus group discussions was used. This study involved 415 undergraduate medical and nursing students from a university in Singapore. After a baseline evaluation of the participants’ sepsis knowledge and team communication skills, they underwent didactic e-learning followed by virtual telesimulation on early recognition and management of sepsis and team communication strategies. The participants’ sepsis knowledge and team communication skills were evaluated immediately and 2 months after the telesimulation. In total, 4 focus group discussions were conducted using a purposive sample of 18 medical and nursing students to explore their transfer of learning to clinical practice. Results: Compared with the baseline scores, both the medical and nursing students demonstrated a significant improvement in sepsis knowledge (P<.001) and team communication skills (P<.001) in immediate posttest scores. At the 2-month follow-up, the nursing students continued to have statistically significantly higher sepsis knowledge (P<.001) and communication scores (P<.001) than the pretest scores, whereas the medical students had no significant changes in test scores between the 2-month follow-up and pretest time points (P=.99). A total of three themes emerged from the qualitative findings: greater understanding of each other’s roles, application of mental models in clinical practice, and theory-practice gaps. The sepsis interprofessional education—particularly the use of virtual telesimulation—fostered participants’ understanding and appreciation of each other’s interprofessional roles when caring for patients with sepsis. Despite noting some incongruities with the real-world clinical practice and not encountering many sepsis scenarios in clinical settings, participants shared the application of mental models using interprofessional communication strategies and the patient assessment framework in their daily clinical practice. Conclusions: Although the study did not show long-term knowledge retention, the use of virtual telesimulation played a critical role in facilitating the application of mental models for learning transfer and therefore could serve as a promising education modality for sepsis training. For a greater clinical effect, future studies could complement virtual telesimulation with a mannequin-based simulation and provide more evidence on the long-term retention of sepsis knowledge and clinical skills performance. %M 35436237 %R 10.2196/35058 %U https://www.jmir.org/2022/4/e35058 %U https://doi.org/10.2196/35058 %U http://www.ncbi.nlm.nih.gov/pubmed/35436237 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e29594 %T Outcomes, Measurement Instruments, and Their Validity Evidence in Randomized Controlled Trials on Virtual, Augmented, and Mixed Reality in Undergraduate Medical Education: Systematic Mapping Review %A Tudor Car,Lorainne %A Kyaw,Bhone Myint %A Teo,Andrew %A Fox,Tatiana Erlikh %A Vimalesvaran,Sunitha %A Apfelbacher,Christian %A Kemp,Sandra %A Chavannes,Niels %+ Lee Kong Chian School of Medicine, Nanyang Technological University, Clinical Sciences Building, 11 Mandalay Road, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K virtual reality %K augmented reality %K mixed reality %K outcomes %K extended reality %K digital education %K randomized controlled trials %K medical education %K measurement instruments %D 2022 %7 13.4.2022 %9 Review %J JMIR Serious Games %G English %X Background: Extended reality, which encompasses virtual reality (VR), augmented reality (AR), and mixed reality (MR), is increasingly used in medical education. Studies assessing the effectiveness of these new educational modalities should measure relevant outcomes using outcome measurement tools with validity evidence. Objective: Our aim is to determine the choice of outcomes, measurement instruments, and the use of measurement instruments with validity evidence in randomized controlled trials (RCTs) on the effectiveness of VR, AR, and MR in medical student education. Methods: We conducted a systematic mapping review. We searched 7 major bibliographic databases from January 1990 to April 2020, and 2 reviewers screened the citations and extracted data independently from the included studies. We report our findings in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Of the 126 retrieved RCTs, 115 (91.3%) were on VR and 11 (8.7%) were on AR. No RCT on MR in medical student education was found. Of the 115 studies on VR, 64 (55.6%) were on VR simulators, 30 (26.1%) on screen-based VR, 9 (7.8%) on VR patient simulations, and 12 (10.4%) on VR serious games. Most studies reported only a single outcome and immediate postintervention assessment data. Skills outcome was the most common outcome reported in studies on VR simulators (97%), VR patient simulations (100%), and AR (73%). Knowledge was the most common outcome reported in studies on screen-based VR (80%) and VR serious games (58%). Less common outcomes included participants’ attitudes, satisfaction, cognitive or mental load, learning efficacy, engagement or self-efficacy beliefs, emotional state, competency developed, and patient outcomes. At least one form of validity evidence was found in approximately half of the studies on VR simulators (55%), VR patient simulations (56%), VR serious games (58%), and AR (55%) and in a quarter of the studies on screen-based VR (27%). Most studies used assessment methods that were implemented in a nondigital format, such as paper-based written exercises or in-person assessments where examiners observed performance (72%). Conclusions: RCTs on VR and AR in medical education report a restricted range of outcomes, mostly skills and knowledge. The studies largely report immediate postintervention outcome data and use assessment methods that are in a nondigital format. Future RCTs should include a broader set of outcomes, report on the validity evidence of the measurement instruments used, and explore the use of assessments that are implemented digitally. %M 35416789 %R 10.2196/29594 %U https://games.jmir.org/2022/2/e29594 %U https://doi.org/10.2196/29594 %U http://www.ncbi.nlm.nih.gov/pubmed/35416789 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e36725 %T Simulation-Based Learning Supported by Technology to Enhance Critical Thinking in Nursing Students: Protocol for a Scoping Review %A Stenseth,Hege Vistven %A Steindal,Simen Alexander %A Solberg,Marianne Trygg %A Ølnes,Mia Alexandra %A Mohallem,Andrea %A Sørensen,Anne Lene %A Strandell-Laine,Camilla %A Olaussen,Camilla %A Aure,Caroline Farsjø %A Riegel,Fernando %A Pedersen,Ingunn %A Zlamal,Jaroslav %A Martini,Jussara Gue %A Bresolin,Paula %A Linnerud,Silje Christin Wang %A Nes,Andréa Aparecida Gonçalves %+ Lovisenberg Diaconal University College, Lovisenbergata 15B, Oslo, 0456, Norway, 47 93840197, hege.vistven@ldh.no %K simulation-based learning %K technological supported simulation-based learning %K critical thinking %K nursing students %K nursing education, educational approach %K education %K nursing %D 2022 %7 4.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Critical thinking is a crucial skill in the nursing profession, so teaching strategies and methodology must be carefully considered when training and preparing nursing students to think critically. Studies on simulation-based learning supported by technology are increasing in nursing education, but no scoping reviews have mapped the literature on simulation-based learning supported by technology to enhance critical thinking in nursing students. Objective: The proposed scoping review aims to systematically map research on the use of simulation-based learning supported by technology to enhance critical thinking in nursing students. Methods: The proposed scoping review will use the framework established by Arksey and O’Malley and will be reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. A systematic, comprehensive literature search was performed in the LILACS, ERIC, MEDLINE, EMBASE, PsycINFO, and Web of Science databases. Pairs of authors independently selected the articles by screening titles, abstracts, full-text papers, and extract data. The data will be analyzed and thematically categorized. Results: The development of a comprehensive and systematic search strategy was completed in June 2021. The database searches were performed in July 2021, and the screening of titles and abstracts was completed in September 2021. Charting the data began in February 2022. Analysis and synthesis will be performed sequentially, and the scoping review is expected to be complete by May 2023. Conclusions: The results of this proposed scoping review may identify gaps in the literature and provide an overview of research on the topic of simulation-based learning supported by technology to enhance critical thinking in nursing students. The research may identify nursing students’ reported barriers and enablers for learning critical thinking skills through simulation-based learning supported by technology, and the results may help educators enhance their educational approach through knowledge of students’ firsthand experiences and further development of successful teaching strategies in nursing education. International Registered Report Identifier (IRRID): DERR1-10.2196/36725 %M 35373777 %R 10.2196/36725 %U https://www.researchprotocols.org/2022/4/e36725 %U https://doi.org/10.2196/36725 %U http://www.ncbi.nlm.nih.gov/pubmed/35373777 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e28595 %T Viewpoint: Virtual and Augmented Reality in Basic and Advanced Life Support Training %A Ricci,Serena %A Calandrino,Andrea %A Borgonovo,Giacomo %A Chirico,Marco %A Casadio,Maura %+ Simulation and Advanced Education Center, University of Genova, Via Pastore 3, Genova, 16132, Italy, 39 01033550188, serena.ricci@edu.unige.it %K basic and advanced life support %K first aid %K cardiopulmonary resuscitation %K emergency %K training %K simulation training %K medical simulation %K healthcare simulation %K virtual reality %K augmented reality %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X The use of augmented reality (AR) and virtual reality (VR) for life support training is increasing. These technologies provide an immersive experience that supports learning in a safe and controlled environment. This review focuses on the use of AR and VR for emergency care training for health care providers, medical students, and nonprofessionals. In particular, we analyzed (1) serious games, nonimmersive games, both single-player and multiplayer; (2) VR tools ranging from semi-immersive to immersive virtual and mixed reality; and (3) AR applications. All the toolkits have been investigated in terms of application goals (training, assessment, or both), simulated procedures, and skills. The main goal of this work is to summarize and organize the findings of studies coming from multiple research areas in order to make them accessible to all the professionals involved in medical simulation. The analysis of the state-of-the-art technologies reveals that tools and studies related to the multiplayer experience, haptic feedback, and evaluation of user’s manual skills in the foregoing health care-related environments are still limited and require further investigation. Also, there is an additional need to conduct studies aimed at assessing whether AR/VR-based systems are superior or, at the minimum, comparable to traditional training methods. %M 35319477 %R 10.2196/28595 %U https://games.jmir.org/2022/1/e28595 %U https://doi.org/10.2196/28595 %U http://www.ncbi.nlm.nih.gov/pubmed/35319477 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 1 %P e24372 %T Learning Analytics Applied to Clinical Diagnostic Reasoning Using a Natural Language Processing–Based Virtual Patient Simulator: Case Study %A Furlan,Raffaello %A Gatti,Mauro %A Mene,Roberto %A Shiffer,Dana %A Marchiori,Chiara %A Giaj Levra,Alessandro %A Saturnino,Vincenzo %A Brunetta,Enrico %A Dipaola,Franca %+ Department of Biomedical Sciences, Humanitas University, 4 Via Rita Levi Montalcini, Milan, 20090, Italy, 39 0282247228, raffaello.furlan@hunimed.eu %K clinical diagnostic reasoning %K learning analytics %K natural language processing %K virtual patient simulator %K medical education %K medical knowledge %D 2022 %7 3.3.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual patient simulators (VPSs) log all users’ actions, thereby enabling the creation of a multidimensional representation of students’ medical knowledge. This representation can be used to create metrics providing teachers with valuable learning information. Objective: The aim of this study is to describe the metrics we developed to analyze the clinical diagnostic reasoning of medical students, provide examples of their application, and preliminarily validate these metrics on a class of undergraduate medical students. The metrics are computed from the data obtained through a novel VPS embedding natural language processing techniques. Methods: A total of 2 clinical case simulations (tests) were created to test our metrics. During each simulation, the students’ step-by-step actions were logged into the program database for offline analysis. The students’ performance was divided into seven dimensions: the identification of relevant information in the given clinical scenario, history taking, physical examination, medical test ordering, diagnostic hypothesis setting, binary analysis fulfillment, and final diagnosis setting. Sensitivity (percentage of relevant information found) and precision (percentage of correct actions performed) metrics were computed for each issue and combined into a harmonic mean (F1), thereby obtaining a single score evaluating the students’ performance. The 7 metrics were further grouped to reflect the students’ capability to collect and to analyze information to obtain an overall performance score. A methodological score was computed based on the discordance between the diagnostic pathway followed by students and the reference one previously defined by the teacher. In total, 25 students attending the fifth year of the School of Medicine at Humanitas University underwent test 1, which simulated a patient with dyspnea. Test 2 dealt with abdominal pain and was attended by 36 students on a different day. For validation, we assessed the Spearman rank correlation between the performance on these scores and the score obtained by each student in the hematology curricular examination. Results: The mean overall scores were consistent between test 1 (mean 0.59, SD 0.05) and test 2 (mean 0.54, SD 0.12). For each student, the overall performance was achieved through a different contribution in collecting and analyzing information. Methodological scores highlighted discordances between the reference diagnostic pattern previously set by the teacher and the one pursued by the student. No significant correlation was found between the VPS scores and hematology examination scores. Conclusions: Different components of the students’ diagnostic process may be disentangled and quantified by appropriate metrics applied to students’ actions recorded while addressing a virtual case. Such an approach may help teachers provide students with individualized feedback aimed at filling competence drawbacks and methodological inconsistencies. There was no correlation between the hematology curricular examination score and any of the proposed scores as these scores address different aspects of students’ medical knowledge. %M 35238786 %R 10.2196/24372 %U https://mededu.jmir.org/2022/1/e24372 %U https://doi.org/10.2196/24372 %U http://www.ncbi.nlm.nih.gov/pubmed/35238786 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30456 %T Virtual Reality Simulation Training for Cardiopulmonary Resuscitation After Cardiac Surgery: Face and Content Validity Study %A Sadeghi,Amir H %A Peek,Jette J %A Max,Samuel A %A Smit,Liselot L %A Martina,Bryan G %A Rosalia,Rodney A %A Bakhuis,Wouter %A Bogers,Ad JJC %A Mahtab,Edris AF %+ Department of Cardiothoracic Surgery, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, 3015 GD, Netherlands, 31 10 704 0704, h.sadeghi@erasmusmc.nl %K cardiac surgery %K cardiopulmonary resuscitation %K emergency resternotomy %K virtual reality %K simulation training %K serious games %K virtual reality simulation %K digital health %K medical training %K virtual training %D 2022 %7 2.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cardiac arrest after cardiac surgery commonly has a reversible cause, where emergency resternotomy is often required for treatment, as recommended by international guidelines. We have developed a virtual reality (VR) simulation for training of cardiopulmonary resuscitation (CPR) and emergency resternotomy procedures after cardiac surgery, the Cardiopulmonary Resuscitation Virtual Reality Simulator (CPVR-sim). Two fictive clinical scenarios were used: one case of pulseless electrical activity (PEA) and a combined case of PEA and ventricular fibrillation. In this prospective study, we researched the face validity and content validity of the CPVR-sim. Objective: We designed a prospective study to assess the feasibility and to establish the face and content validity of two clinical scenarios (shockable and nonshockable cardiac arrest) of the CPVR-sim partly divided into a group of novices and experts in performing CPR and emergency resternotomies in patients after cardiac surgery. Methods: Clinicians (staff cardiothoracic surgeons, physicians, surgical residents, nurse practitioners, and medical students) participated in this study and performed two different scenarios, either PEA or combined PEA and ventricular fibrillation. All participants (N=41) performed a simulation and completed the questionnaire rating the simulator’s usefulness, satisfaction, ease of use, effectiveness, and immersiveness to assess face validity and content validity. Results: Responses toward face validity and content validity were predominantly positive in both groups. Most participants in the PEA scenario (n=26, 87%) felt actively involved in the simulation, and 23 (77%) participants felt in charge of the situation. The participants thought it was easy to learn how to interact with the software (n=24, 80%) and thought that the software responded adequately (n=21, 70%). All 15 (100%) expert participants preferred VR training as an addition to conventional training. Moreover, 13 (87%) of the expert participants would recommend VR training to other colleagues, and 14 (93%) of the expert participants thought the CPVR-sim was a useful method to train for infrequent post–cardiac surgery emergencies requiring CPR. Additionally, 10 (91%) of the participants thought it was easy to move in the VR environment, and that the CPVR-sim responded adequately in this scenario. Conclusions: We developed a proof-of-concept VR simulation for CPR training with two scenarios of a patient after cardiac surgery, which participants found was immersive and useful. By proving the face validity and content validity of the CPVR-sim, we present the first step toward a cardiothoracic surgery VR training platform. %M 35234652 %R 10.2196/30456 %U https://games.jmir.org/2022/1/e30456 %U https://doi.org/10.2196/30456 %U http://www.ncbi.nlm.nih.gov/pubmed/35234652 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e33459 %T Teaching Students About Plagiarism Using a Serious Game (Plagi-Warfare): Design and Evaluation Study %A Ade-Ibijola,Abejide %A Young,Keagan %A Sivparsad,Nashik %A Seforo,Mpho %A Ally,Suhail %A Olowolafe,Adebola %A Frahm-Arp,Maria %+ Johannesburg Business School, University of Johannesburg, Barry Hertzog Ave &, Empire Rd, Milpark, Johannesburg, 2092, South Africa, 27 11 559 1774, abejideai@uj.ac.za %K serious games %K educational games %K plagiarism %K library games %K game mechanics %K education %K teaching %D 2022 %7 16.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Educational games have been proven to support the teaching of various concepts across disciplines. Plagiarism is a major problem among undergraduate and postgraduate students at universities. Objective: In this paper, we propose a game called Plagi-Warfare that attempts to teach students about plagiarism. Methods: To do this at a level that is beyond quizzes, we proposed a game storyline and mechanics that allow the player (or student) to play as a mafia member or a detective. This either demonstrated their knowledge by plagiarizing within the game as a mafia member or catching plagiarists within the game as a detective. The game plays out in a 3D environment representing the major libraries of the University of Johannesburg, South Africa. In total, 30 students were selected to evaluate the game. Results: Evaluation of the game mechanics and storyline showed that the student gamers enjoyed the game and learned about plagiarism. Conclusions: In this paper, we presented a new educational game that teaches students about plagiarism by using a new crime story and an immersive 3D gaming environment representing the libraries of the University of Johannesburg. %M 35171103 %R 10.2196/33459 %U https://games.jmir.org/2022/1/e33459 %U https://doi.org/10.2196/33459 %U http://www.ncbi.nlm.nih.gov/pubmed/35171103 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e31042 %T Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial %A Burgon,Trever %A Casebeer,Linda %A Aasen,Holly %A Valdenor,Czarlota %A Tamondong-Lachica,Diana %A de Belen,Enrico %A Paculdo,David %A Peabody,John %+ QURE Healthcare, 450 Pacific Ave, Suite 200, San Francisco, CA, 94133, United States, 1 4153213388 ext 101, jpeabody@qurehealthcare.com %K quality improvement %K physician engagement %K MIPS %K case simulation %K feedback %K value-based care %K care standardization %K simulation %K gamification %K medical education %K continuing education %K outcome %K serious game %K decision-support %D 2021 %7 23.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients. Objective: In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS). Methods: We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians “cared” for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient. Results: We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, P<.001) and osteoarthritis (+7.6%, P=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, P<.001), depression screening (+11%, P<.001), and asthma medications (+33%, P<.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases. Conclusions: Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians. Trial Registration: ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901 %M 34941547 %R 10.2196/31042 %U https://www.jmir.org/2021/12/e31042 %U https://doi.org/10.2196/31042 %U http://www.ncbi.nlm.nih.gov/pubmed/34941547 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 4 %P e30440 %T Simulation-Based Teaching of Telemedicine for Future Users of Teleconsultation and Tele-Expertise: Feasibility Study %A Bouamra,Benjamin %A Chakroun,Karim %A Medeiros De Bustos,Elisabeth %A Dobson,Jennifer %A Rouge,Jeanne-Antide %A Moulin,Thierry %+ Department of Neurology, Besançon University Hospital, 3 boulevard Alexandre Fleming, Besançon, 25000, France, 33 0687434404, benjamin.bouamra@wanadoo.fr %K telemedicine %K teleconsultation %K simulation training %K health care %K training %K education %K digital training %K medical education %D 2021 %7 22.12.2021 %9 Original Paper %J JMIR Med Educ %G English %X Background: Health care professionals worldwide are increasingly using telemedicine in their daily clinical practice. However, there is still a lack of dedicated education and training even though it is needed to improve the quality of the diverse range of telemedicine activities. Simulation-based training may be a useful tool in telemedicine education and training delivery. Objective: This study aims to assess the feasibility and acceptability of simulation-based telemedicine training. Methods: We assessed five telemedicine training sessions conducted in a simulation laboratory. The training was focused on video teleconsultations between a patient and a health care professional. The assessment included the participants’ satisfaction and attitudes toward the training. Results: We included 29 participants in total. Participant satisfaction was high (mean score 4.9 of 5), and those that took part stated the high applicability of the simulation-based training to their telemedicine practices (mean score 4.6 of 5). They also stated that they intended to use telemedicine in the future (mean score 4.5 of 5). Conclusions: Simulation-based training of telemedicine dedicated to video teleconsultation was feasible and showed high satisfaction from participants. However, it remains difficult to scale for a high number of health care professionals. %M 34941553 %R 10.2196/30440 %U https://mededu.jmir.org/2021/4/e30440 %U https://doi.org/10.2196/30440 %U http://www.ncbi.nlm.nih.gov/pubmed/34941553 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e33540 %T How Clinicians Perceive Artificial Intelligence–Assisted Technologies in Diagnostic Decision Making: Mixed Methods Approach %A Hah,Hyeyoung %A Goldin,Deana Shevit %+ Information Systems and Business Analytics, College of Business, Florida International University, 11200 SW 8th Street, Miami, FL, 33199, United States, 1 3053484342, hhah@fiu.edu %K artificial intelligence algorithms %K AI %K diagnostic capability %K virtual care %K multilevel modeling %K human-AI teaming %K natural language understanding %D 2021 %7 16.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: With the rapid development of artificial intelligence (AI) and related technologies, AI algorithms are being embedded into various health information technologies that assist clinicians in clinical decision making. Objective: This study aimed to explore how clinicians perceive AI assistance in diagnostic decision making and suggest the paths forward for AI-human teaming for clinical decision making in health care. Methods: This study used a mixed methods approach, utilizing hierarchical linear modeling and sentiment analysis through natural language understanding techniques. Results: A total of 114 clinicians participated in online simulation surveys in 2020 and 2021. These clinicians studied family medicine and used AI algorithms to aid in patient diagnosis. Their overall sentiment toward AI-assisted diagnosis was positive and comparable with diagnoses made without the assistance of AI. However, AI-guided decision making was not congruent with the way clinicians typically made decisions in diagnosing illnesses. In a quantitative survey, clinicians reported perceiving current AI assistance as not likely to enhance diagnostic capability and negatively influenced their overall performance (β=–0.421, P=.02). Instead, clinicians’ diagnostic capabilities tended to be associated with well-known parameters, such as education, age, and daily habit of technology use on social media platforms. Conclusions: This study elucidated clinicians’ current perceptions and sentiments toward AI-enabled diagnosis. Although the sentiment was positive, the current form of AI assistance may not be linked with efficient decision making, as AI algorithms are not well aligned with subjective human reasoning in clinical diagnosis. Developers and policy makers in health could gather behavioral data from clinicians in various disciplines to help align AI algorithms with the unique subjective patterns of reasoning that humans employ in clinical diagnosis. %M 34924356 %R 10.2196/33540 %U https://www.jmir.org/2021/12/e33540 %U https://doi.org/10.2196/33540 %U http://www.ncbi.nlm.nih.gov/pubmed/34924356 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 4 %P e32356 %T Assessment of Entrustable Professional Activities Using a Web-Based Simulation Platform During Transition to Emergency Medicine Residency: Mixed Methods Pilot Study %A Peng,Cynthia R %A Schertzer,Kimberly A %A Caretta-Weyer,Holly A %A Sebok-Syer,Stefanie S %A Lu,William %A Tansomboon,Charissa %A Gisondi,Michael A %+ Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Rd, Palo Alto, CA, 94304-1805, United States, 1 6507235111, crp34@cornell.edu %K simulation %K graduate medical education %K assessment %K gamification %K entrustable professional activities %K emergency medicine %K undergraduate medical education %D 2021 %7 17.11.2021 %9 Original Paper %J JMIR Med Educ %G English %X Background: The 13 core entrustable professional activities (EPAs) are key competency-based learning outcomes in the transition from undergraduate to graduate medical education in the United States. Five of these EPAs (EPA2: prioritizing differentials, EPA3: recommending and interpreting tests, EPA4: entering orders and prescriptions, EPA5: documenting clinical encounters, and EPA10: recognizing urgent and emergent conditions) are uniquely suited for web-based assessment. Objective: In this pilot study, we created cases on a web-based simulation platform for the diagnostic assessment of these EPAs and examined the feasibility and acceptability of the platform. Methods: Four simulation cases underwent 3 rounds of consensus panels and pilot testing. Incoming emergency medicine interns (N=15) completed all cases. A maximum of 4 “look for” statements, which encompassed specific EPAs, were generated for each participant: (1) performing harmful or missing actions, (2) narrowing differential or wrong final diagnosis, (3) errors in documentation, and (4) lack of recognition and stabilization of urgent diagnoses. Finally, we interviewed a sample of interns (n=5) and residency leadership (n=5) and analyzed the responses using thematic analysis. Results: All participants had at least one missing critical action, and 40% (6/15) of the participants performed at least one harmful action across all 4 cases. The final diagnosis was not included in the differential diagnosis in more than half of the assessments (8/15, 54%). Other errors included selecting incorrect documentation passages (6/15, 40%) and indiscriminately applying oxygen (9/15, 60%). The interview themes included psychological safety of the interface, ability to assess learning, and fidelity of cases. The most valuable feature cited was the ability to place orders in a realistic electronic medical record interface. Conclusions: This study demonstrates the feasibility and acceptability of a web-based platform for diagnostic assessment of specific EPAs. The approach rapidly identifies potential areas of concern for incoming interns using an asynchronous format, provides feedback in a manner appreciated by residency leadership, and informs individualized learning plans. %M 34787582 %R 10.2196/32356 %U https://mededu.jmir.org/2021/4/e32356 %U https://doi.org/10.2196/32356 %U http://www.ncbi.nlm.nih.gov/pubmed/34787582 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 4 %P e31132 %T Use of an Online Ultrasound Simulator to Teach Basic Psychomotor Skills to Medical Students During the Initial COVID-19 Lockdown: Quality Control Study %A Meuwly,Jean-Yves %A Mandralis,Katerina %A Tenisch,Estelle %A Gullo,Giuseppe %A Frossard,Pierre %A Morend,Laura %+ Department of Radiology, University Hospital of Lausanne, University of Lausanne, Rue du Bugnon 46, Lausanne, 1011, Switzerland, 41 795565334, Jean-Yves.Meuwly@chuv.ch %K anatomy %K computers in anatomical education %K internet application in anatomy %K medical education %K ultrasonography %K ultrasound %K simulation %K simulator %K psychomotor %K motor skills %K medical students %K teaching %D 2021 %7 1.11.2021 %9 Original Paper %J JMIR Med Educ %G English %X Background: Teaching medical ultrasound has increased in popularity in medical schools with hands-on workshops as an essential part of teaching. However, the lockdown due to COVID-19 kept medical schools from conducting these workshops. Objective: The aim of this paper is to describe an alternative method used by our medical school to allow our students to acquire the essential psychomotor skills to produce ultrasound images. Methods: Our students took online ultrasound courses. Consequently, they had to practice ultrasound exercises on a virtual simulator, using the mouse of their computer to control a simulated transducer. Our team measured the precision reached at the completion of simulation exercises. Before and after completion of the courses and simulator’s exercises, students had to complete a questionnaire dedicated to psychomotor skills. A general evaluation questionnaire was also submitted. Results: A total of 193 students returned the precourse questionnaire. A total of 184 performed all the simulator exercises and 181 answered the postcourse questionnaire. Of the 180 general evaluation questionnaires that were sent out, 136 (76%) were returned. The average precourse score was 4.23 (SD 2.14). After exercising, the average postcourse score was 6.36 (SD 1.82), with a significant improvement (P<.001). The postcourse score was related to the accuracy with which the simulator exercises were performed (Spearman rho 0.2664; P<.001). Nearly two-thirds (n=84, 62.6%) of the students said they enjoyed working on the simulator. A total of 79 (58.0%) students felt that they had achieved the course’s objective of reproducing ultrasound images. Inadequate connection speed had been a problem for 40.2% (n=54) of students. Conclusions: The integration of an online simulator for the practical learning of ultrasound in remote learning situations has allowed for substantial acquisitions in the psychomotor field of ultrasound diagnosis. Despite the absence of workshops, the students were able to learn and practice how to handle an ultrasound probe to reproduce standard images. This study enhances the value of online programs in medical education, even for practical skills. %M 34723818 %R 10.2196/31132 %U https://mededu.jmir.org/2021/4/e31132 %U https://doi.org/10.2196/31132 %U http://www.ncbi.nlm.nih.gov/pubmed/34723818 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 10 %P e17472 %T Augmented Reality for Guideline Presentation in Medicine: Randomized Crossover Simulation Trial for Technically Assisted Decision-making %A Follmann,Andreas %A Ruhl,Alexander %A Gösch,Michael %A Felzen,Marc %A Rossaint,Rolf %A Czaplik,Michael %+ Department of Anesthesiology, Faculty of Medicine, Rheinisch-Westfälische Technische Hochschule Aachen University, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 36219, afollmann@ukaachen.de %K augmented reality %K smart glasses %K wearables %K guideline presentation %K decision support %K triage %D 2021 %7 18.10.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Guidelines provide instructions for diagnostics and therapy in modern medicine. Various mobile devices are used to represent the potential complex decision trees. An example of time-critical decisions is triage in case of a mass casualty incident. Objective: In this randomized controlled crossover study, the potential of augmented reality for guideline presentation was evaluated and compared with the guideline presentation provided in a tablet PC as a conventional device. Methods: A specific Android app was designed for use with smart glasses and a tablet PC for the presentation of a triage algorithm as an example for a complex guideline. Forty volunteers simulated a triage based on 30 fictional patient descriptions, each with technical support from smart glasses and a tablet PC in a crossover trial design. The time to come to a decision and the accuracy were recorded and compared between both devices. Results: A total of 2400 assessments were performed by the 40 volunteers. A significantly faster time to triage was achieved in total with the tablet PC (median 12.8 seconds, IQR 9.4-17.7; 95% CI 14.1-14.9) compared to that to triage with smart glasses (median 17.5 seconds, IQR 13.2-22.8, 95% CI 18.4-19.2; P=.001). Considering the difference in the triage time between both devices, the additional time needed with the smart glasses could be reduced significantly in the course of assessments (21.5 seconds, IQR 16.5-27.3, 95% CI 21.6-23.2) in the first run, 17.4 seconds (IQR 13-22.4, 95% CI 17.6-18.9) in the second run, and 14.9 seconds (IQR 11.7-18.6, 95% CI 15.2-16.3) in the third run (P=.001). With regard to the accuracy of the guideline decisions, there was no significant difference between both the devices. Conclusions: The presentation of a guideline on a tablet PC as well as through augmented reality achieved good results. The implementation with smart glasses took more time owing to their more complex operating concept but could be accelerated in the course of the study after adaptation. Especially in a non–time-critical working area where hands-free interfaces are useful, a guideline presentation with augmented reality can be of great use during clinical management. %M 34661548 %R 10.2196/17472 %U https://mhealth.jmir.org/2021/10/e17472 %U https://doi.org/10.2196/17472 %U http://www.ncbi.nlm.nih.gov/pubmed/34661548 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 4 %P e29899 %T Augmented Reality in Pediatric Septic Shock Simulation: Randomized Controlled Feasibility Trial %A Toto,Regina L %A Vorel,Ethan S %A Tay,Khoon-Yen E %A Good,Grace L %A Berdinka,Jesse M %A Peled,Adam %A Leary,Marion %A Chang,Todd P %A Weiss,Anna K %A Balamuth,Frances B %+ Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, United States, 1 2155901000, totor@chop.edu %K augmented reality %K simulation %K septic shock %K children %K pediatrics %K simulation-based education %K application %K fluid administration %D 2021 %7 6.10.2021 %9 Original Paper %J JMIR Med Educ %G English %X Background: Septic shock is a low-frequency but high-stakes condition in children requiring prompt resuscitation, which makes it an important target for simulation-based education. Objective: In this study, we aimed to design and implement an augmented reality app (PediSepsisAR) for septic shock simulation, test the feasibility of measuring the timing and volume of fluid administration during septic shock simulation with and without PediSepsisAR, and describe PediSepsisAR as an educational tool. We hypothesized that we could feasibly measure our desired data during the simulation in 90% of the participants in each group. With regard to using PediSepsisAR as an educational tool, we hypothesized that the PediSepsisAR group would report that it enhanced their awareness of simulated patient blood flow and would more rapidly verbalize recognition of abnormal patient status and desired management steps. Methods: We performed a randomized controlled feasibility trial with a convenience sample of pediatric care providers at a large tertiary care pediatric center. Participants completed a prestudy questionnaire and were randomized to either the PediSepsisAR or control (traditional simulation) arms. We measured the participants’ time to administer 20, 40, and 60 cc/kg of intravenous fluids during a septic shock simulation using each modality. In addition, facilitators timed how long participants took to verbalize they had recognized tachycardia, hypotension, or septic shock and desired to initiate the sepsis pathway and administer antibiotics. Participants in the PediSepsisAR arm completed a poststudy questionnaire. We analyzed data using descriptive statistics and a Wilcoxon rank-sum test to compare the median time with event variables between groups. Results: We enrolled 50 participants (n=25 in each arm). The timing and volume of fluid administration were captured in all the participants in each group. There was no statistically significant difference regarding time to administration of intravenous fluids between the two groups. Similarly, there was no statistically significant difference between the groups regarding time to verbalized recognition of patient status or desired management steps. Most participants in the PediSepsisAR group reported that PediSepsisAR enhanced their awareness of the patient’s perfusion. Conclusions: We developed an augmented reality app for use in pediatric septic shock simulations and demonstrated the feasibility of measuring the volume and timing of fluid administration during simulation using this modality. In addition, our findings suggest that PediSepsisAR may enhance participants’ awareness of abnormal perfusion. %M 34612836 %R 10.2196/29899 %U https://mededu.jmir.org/2021/4/e29899 %U https://doi.org/10.2196/29899 %U http://www.ncbi.nlm.nih.gov/pubmed/34612836 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e26802 %T Mechanism Design of Health Care Blockchain System Token Economy: Development Study Based on Simulated Real-World Scenarios %A Jung,Se Young %A Kim,Taehyun %A Hwang,Hyung Ju %A Hong,Kyungpyo %+ Department of Mathematics, Pohang University of Science and Technology, 77, Cheongam-ro, Nam-gu, Pohang-si, 37673, Republic of Korea, 82 054 279 2056, hjhwang@postech.ac.kr %K mechanism design %K optimization %K blockchain %K token economy %K eHealth %K electronic health records %K healthcare %K economy %K health records %D 2021 %7 13.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the fact that the adoption rate of electronic health records has increased dramatically among high-income nations, it is still difficult to properly disseminate personal health records. Token economy, through blockchain smart contracts, can better distribute personal health records by providing incentives to patients. However, there have been very few studies regarding the particular factors that should be considered when designing incentive mechanisms in blockchain. Objective: The aim of this paper is to provide 2 new mathematical models of token economy in real-world scenarios on health care blockchain platforms. Methods: First, roles were set for the health care blockchain platform and its token flow. Second, 2 scenarios were introduced: collecting life-log data for an incentive program at a life insurance company to motivate customers to exercise more and recruiting participants for clinical trials of anticancer drugs. In our 2 scenarios, we assumed that there were 3 stakeholders: participants, data recipients (companies), and data providers (health care organizations). We also assumed that the incentives are initially paid out to participants by data recipients, who are focused on minimizing economic and time costs by adapting mechanism design. This concept can be seen as a part of game theory, since the willingness-to-pay of data recipients is important in maintaining the blockchain token economy. In both scenarios, the recruiting company can change the expected recruitment time and number of participants. Suppose a company considers the recruitment time to be more important than the number of participants and rewards. In that case, the company can increase the time weight and adjust cost. When the reward parameter is fixed, the corresponding expected recruitment time can be obtained. Among the reward and time pairs, the pair that minimizes the company’s cost was chosen. Finally, the optimized results were compared with the simulations and analyzed accordingly. Results: To minimize the company’s costs, reward–time pairs were first collected. It was observed that the expected recruitment time decreased as rewards grew, while the rewards decreased as time cost grew. Therefore, the cost was represented by a convex curve, which made it possible to obtain a minimum—an optimal point—for both scenarios. Through sensitivity analysis, we observed that, as the time weight increased, the optimized reward increased, while the optimized time decreased. Moreover, as the number of participants increased, the optimization reward and time also increased. Conclusions: In this study, we were able to model the incentive mechanism of blockchain based on a mechanism design that recruits participants through a health care blockchain platform. This study presents a basic approach to incentive modeling in personal health records, demonstrating how health care organizations and funding companies can motivate one another to join the platform. %M 34515640 %R 10.2196/26802 %U https://www.jmir.org/2021/9/e26802 %U https://doi.org/10.2196/26802 %U http://www.ncbi.nlm.nih.gov/pubmed/34515640 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e24081 %T A 3D Hologram With Mixed Reality Techniques to Improve Understanding of Pulmonary Lesions Caused by COVID-19: Randomized Controlled Trial %A Liu,Songxiang %A Xie,Mao %A Zhang,Zhicai %A Wu,Xinghuo %A Gao,Fei %A Lu,Lin %A Zhang,Jiayao %A Xie,Yi %A Yang,Fan %A Ye,Zhewei %+ Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430019, China, 86 13971213880, yezhewei@hust.edu.cn %K COVID-19 %K mixed reality %K hologram %K pulmonary %K lesion %K diagnostic %K imaging %D 2021 %7 10.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 outbreak has now become a pandemic and has had a serious adverse impact on global public health. The effect of COVID-19 on the lungs can be determined through 2D computed tomography (CT) imaging, which requires a high level of spatial imagination on the part of the medical provider. Objective: The purpose of this study is to determine whether viewing a 3D hologram with mixed reality techniques can improve medical professionals’ understanding of the pulmonary lesions caused by COVID-19. Methods: The study involved 60 participants, including 20 radiologists, 20 surgeons, and 20 medical students. Each of the three groups was randomly divided into two groups, either the 2D CT group (n=30; mean age 29 years [range 19-38 years]; males=20) or the 3D holographic group (n=30; mean age 30 years [range 20=38 years]; males=20). The two groups completed the same task, which involved identifying lung lesions caused by COVID-19 for 6 cases using a 2D CT or 3D hologram. Finally, an independent radiology professor rated the participants' performance (out of 100). All participants in two groups completed a Likert scale questionnaire regarding the educational utility and efficiency of 3D holograms. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) was completed by all participants. Results: The mean task score of the 3D hologram group (mean 91.98, SD 2.45) was significantly higher than that of the 2D CT group (mean 74.09, SD 7.59; P<.001). With the help of 3D holograms, surgeons and medical students achieved the same score as radiologists and made obvious progress in identifying pulmonary lesions caused by COVID-19. The Likert scale questionnaire results showed that the 3D hologram group had superior results compared to the 2D CT group (teaching: 2D CT group median 2, IQR 1-2 versus 3D group median 5, IQR 5-5; P<.001; understanding and communicating: 2D CT group median 1, IQR 1-1 versus 3D group median 5, IQR 5-5; P<.001; increasing interest: 2D CT group median 2, IQR 2-2 versus 3D group median 5, IQR 5-5; P<.001; lowering the learning curve: 2D CT group median 2, IQR 1-2 versus 3D group median 4, IQR 4-5; P<.001; spatial awareness: 2D CT group median 2, IQR 1-2 versus 3D group median 5, IQR 5-5; P<.001; learning: 2D CT group median 3, IQR 2-3 versus 3D group median 5, IQR 5-5; P<.001). The 3D group scored significantly lower than the 2D CT group for the “mental,” “temporal,” “performance,” and “frustration” subscales on the NASA-TLX. Conclusions: A 3D hologram with mixed reality techniques can be used to help medical professionals, especially medical students and newly hired doctors, better identify pulmonary lesions caused by COVID-19. It can be used in medical education to improve spatial awareness, increase interest, improve understandability, and lower the learning curve. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100045845; http://www.chictr.org.cn/showprojen.aspx?proj=125761 %M 34061760 %R 10.2196/24081 %U https://www.jmir.org/2021/9/e24081 %U https://doi.org/10.2196/24081 %U http://www.ncbi.nlm.nih.gov/pubmed/34061760 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 9 %P e29498 %T Nursing Interns’ Attitudes Toward, Preferences for, and Use of Diabetes Virtual Simulation Teaching Applications in China: National Web-Based Survey %A Liu,Fang %A Weng,Huiting %A Xu,Rong %A Li,Xia %A Zhang,Zhe %A Zhao,Kuaile %A Zhou,Zhiguang %A Wang,Qin %+ Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, China, 86 18774806226, wangqin3421@csu.edu.cn %K nursing interns %K virtual simulation %K China %K nursing education %K diabetes %D 2021 %7 9.9.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Diabetes has placed heavy social and economic burdens on society and families worldwide. Insufficient knowledge and training of frontline medical staff, such as nurses, interns, and residents, may lead to an increase in acute and chronic complications among patients with diabetes. However, interns have insufficient knowledge about diabetes management. The factors that affect interns’ current level of diabetes-related knowledge are still unclear. Therefore, understanding the behavioral intentions of interns is essential to supporting the development and promotion of the use of virtual simulation teaching applications. Objective: This study aimed to identify the determinants of nursing interns’ intentions to use simulation-based education applications. Methods: From December 1, 2020, to February 28, 2021, the web-based survey tool Sojump (Changsha Xingxin Information Technology Co) was used to survey nursing interns in hospitals across China. Two survey links were sent to 37 partner schools in 23 major cities in China, and they were disseminated through participants’ WeChat networks. Multiple regression analysis was used to determine the association between demographic information and basic disease information and the use of the application for treating adult patients. Results: Overall, 883 nursing interns from 23 provinces in China responded to the survey. Among them, the virtual simulation utilization rate was 35.6% (314/883) and the awareness rate was 10.2% (90/883). In addition, among the interns, only 10.2% (90/883) correctly understood the concept of virtual simulation, and most of them (793/883, 89.8%) believed that scenario-simulation training or the use of models for teaching are all the same. Multiple regression analysis showed that the educational level, independent learning ability, and professional identity of the interns were related to use of the application (P<.05). Skills and knowledge that the interns most wanted to acquire included the treatment of hypoglycemia (626/883, 70.9%), functional test simulation (610/883, 69.1%), and blood glucose monitoring technology (485/883, 54.9%). A total of 60.5% (534/883) of the interns wanted to acquire clinical thinking skills, while 16.0% (141/883) wanted to acquire operational skills. Nursing trainees believed that the greatest obstacles to virtual simulation included limited time (280/883, 31.7%), the degree of simulation (129/883, 14.6%), the demand for satisfaction (108/883, 12.2%), and test scores (66/883, 7.5%). Conclusions: The understanding and usage rate of diabetes virtual simulation teaching applications by Chinese nursing interns is very low. However, they have high requirements regarding this teaching method. Conducting high-quality randomized controlled trials and designing applications that are suitable for the needs of different nurse trainees will increase students’ interest in learning and help improve diabetes knowledge among nursing interns. %M 34499047 %R 10.2196/29498 %U https://mhealth.jmir.org/2021/9/e29498 %U https://doi.org/10.2196/29498 %U http://www.ncbi.nlm.nih.gov/pubmed/34499047 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 9 %N 4 %P e27419 %T Returning to a Normal Life via COVID-19 Vaccines in the United States: A Large-scale Agent-Based Simulation Study %A Li,Junjiang %A Giabbanelli,Philippe %+ Department of Computer Science & Software Engineering, Miami University, 205 Benton Hall, Oxford, OH, 45056, United States, 1 513 529 0147, aqualonne@free.fr %K agent-based model %K cloud-based simulations %K COVID-19 %K large-scale simulations %K vaccine %K model %K simulation %K United States %K agent-based %K effective %K willingness %K capacity %K plan %K strategy %K outcome %K interaction %K intervention %K scenario %K impact %D 2021 %7 29.4.2021 %9 Original Paper %J JMIR Med Inform %G English %X Background: In 2020, COVID-19 has claimed more than 300,000 deaths in the United States alone. Although nonpharmaceutical interventions were implemented by federal and state governments in the United States, these efforts have failed to contain the virus. Following the Food and Drug Administration's approval of two COVID-19 vaccines, however, the hope for the return to normalcy has been renewed. This hope rests on an unprecedented nationwide vaccine campaign, which faces many logistical challenges and is also contingent on several factors whose values are currently unknown. Objective: We study the effectiveness of a nationwide vaccine campaign in response to different vaccine efficacies, the willingness of the population to be vaccinated, and the daily vaccine capacity under two different federal plans. To characterize the possible outcomes most accurately, we also account for the interactions between nonpharmaceutical interventions and vaccines through 6 scenarios that capture a range of possible impacts from nonpharmaceutical interventions. Methods: We used large-scale, cloud-based, agent-based simulations by implementing the vaccination campaign using COVASIM, an open-source agent-based model for COVID-19 that has been used in several peer-reviewed studies and accounts for individual heterogeneity and a multiplicity of contact networks. Several modifications to the parameters and simulation logic were made to better align the model with current evidence. We chose 6 nonpharmaceutical intervention scenarios and applied the vaccination intervention following both the plan proposed by Operation Warp Speed (former Trump administration) and the plan of one million vaccines per day, proposed by the Biden administration. We accounted for unknowns in vaccine efficacies and levels of population compliance by varying both parameters. For each experiment, the cumulative infection growth was fitted to a logistic growth model, and the carrying capacities and the growth rates were recorded. Results: For both vaccination plans and all nonpharmaceutical intervention scenarios, the presence of the vaccine intervention considerably lowers the total number of infections when life returns to normal, even when the population compliance to vaccines is as low as 20%. We noted an unintended consequence; given the vaccine availability estimates under both federal plans and the focus on vaccinating individuals by age categories, a significant reduction in nonpharmaceutical interventions results in a counterintuitive situation in which higher vaccine compliance then leads to more total infections. Conclusions: Although potent, vaccines alone cannot effectively end the pandemic given the current availability estimates and the adopted vaccination strategy. Nonpharmaceutical interventions need to continue and be enforced to ensure high compliance so that the rate of immunity established by vaccination outpaces that induced by infections. %M 33872188 %R 10.2196/27419 %U https://medinform.jmir.org/2021/4/e27419 %U https://doi.org/10.2196/27419 %U http://www.ncbi.nlm.nih.gov/pubmed/33872188 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 9 %N 4 %P e24073 %T A Natural Language Processing–Based Virtual Patient Simulator and Intelligent Tutoring System for the Clinical Diagnostic Process: Simulator Development and Case Study %A Furlan,Raffaello %A Gatti,Mauro %A Menè,Roberto %A Shiffer,Dana %A Marchiori,Chiara %A Giaj Levra,Alessandro %A Saturnino,Vincenzo %A Brunetta,Enrico %A Dipaola,Franca %+ Department of Biomedical Sciences, Humanitas University, Via R Levi Montalcini, 4, Pieve Emanuele, Milan, 20090, Italy, 39 0282247228, raffaello.furlan@hunimed.eu %K COVID-19 %K intelligent tutoring system %K virtual patient simulator %K natural language processing %K artificial intelligence %K clinical diagnostic reasoning %D 2021 %7 9.4.2021 %9 Original Paper %J JMIR Med Inform %G English %X Background: Shortage of human resources, increasing educational costs, and the need to keep social distances in response to the COVID-19 worldwide outbreak have prompted the necessity of clinical training methods designed for distance learning. Virtual patient simulators (VPSs) may partially meet these needs. Natural language processing (NLP) and intelligent tutoring systems (ITSs) may further enhance the educational impact of these simulators. Objective: The goal of this study was to develop a VPS for clinical diagnostic reasoning that integrates interaction in natural language and an ITS. We also aimed to provide preliminary results of a short-term learning test administered on undergraduate students after use of the simulator. Methods: We trained a Siamese long short-term memory network for anamnesis and NLP algorithms combined with Systematized Nomenclature of Medicine (SNOMED) ontology for diagnostic hypothesis generation. The ITS was structured on the concepts of knowledge, assessment, and learner models. To assess short-term learning changes, 15 undergraduate medical students underwent two identical tests, composed of multiple-choice questions, before and after performing a simulation by the virtual simulator. The test was made up of 22 questions; 11 of these were core questions that were specifically designed to evaluate clinical knowledge related to the simulated case. Results: We developed a VPS called Hepius that allows students to gather clinical information from the patient’s medical history, physical exam, and investigations and allows them to formulate a differential diagnosis by using natural language. Hepius is also an ITS that provides real-time step-by-step feedback to the student and suggests specific topics the student has to review to fill in potential knowledge gaps. Results from the short-term learning test showed an increase in both mean test score (P<.001) and mean score for core questions (P<.001) when comparing presimulation and postsimulation performance. Conclusions: By combining ITS and NLP technologies, Hepius may provide medical undergraduate students with a learning tool for training them in diagnostic reasoning. This may be particularly useful in a setting where students have restricted access to clinical wards, as is happening during the COVID-19 pandemic in many countries worldwide. %M 33720840 %R 10.2196/24073 %U https://medinform.jmir.org/2021/4/e24073 %U https://doi.org/10.2196/24073 %U http://www.ncbi.nlm.nih.gov/pubmed/33720840 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e23635 %T The Current Situation and Future Prospects of Simulators in Dental Education %A Li,Yaning %A Ye,Hongqiang %A Ye,Fan %A Liu,Yunsong %A Lv,Longwei %A Zhang,Ping %A Zhang,Xiao %A Zhou,Yongsheng %+ Department of Prosthodontics, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Avenue, Haidian District, Beijing, 100081, China, 86 010 82195070, kqzhouysh@hsc.pku.edu.cn %K dental simulator %K dental education %K virtual reality %D 2021 %7 8.4.2021 %9 Viewpoint %J J Med Internet Res %G English %X The application of virtual reality has become increasingly extensive as this technology has developed. In dental education, virtual reality is mainly used to assist or replace traditional methods of teaching clinical skills in preclinical training for several subjects, such as endodontics, prosthodontics, periodontics, implantology, and dental surgery. The application of dental simulators in teaching can make up for the deficiency of traditional teaching methods and reduce the teaching burden, improving convenience for both teachers and students. However, because of the technology limitations of virtual reality and force feedback, dental simulators still have many hardware and software disadvantages that have prevented them from being an alternative to traditional dental simulators as a primary skill training method. In the future, when combined with big data, cloud computing, 5G, and deep learning technology, dental simulators will be able to give students individualized learning assistance, and their functions will be more diverse and suitable for preclinical training. The purpose of this review is to provide an overview of current dental simulators on related technologies, advantages and disadvantages, methods of evaluating effectiveness, and future directions for development. %M 33830059 %R 10.2196/23635 %U https://www.jmir.org/2021/4/e23635 %U https://doi.org/10.2196/23635 %U http://www.ncbi.nlm.nih.gov/pubmed/33830059 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 1 %P e25828 %T The Impact of Electronic Health Record–Based Simulation During Intern Boot Camp: Interventional Study %A Miller,Matthew E %A Scholl,Gretchen %A Corby,Sky %A Mohan,Vishnu %A Gold,Jeffrey A %+ Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail code UHN67, Portland, OR, 97239, United States, 1 5034181496, goldje@ohsu.edu %K electronic health records %K medical education %K simulation %K usability %K training %D 2021 %7 9.3.2021 %9 Original Paper %J JMIR Med Educ %G English %X Background: Accurate data retrieval is an essential part of patient care in the intensive care unit (ICU). The electronic health record (EHR) is the primary method for data storage and data review. We previously reported that residents participating in EHR-based simulations have varied and nonstandard approaches to finding data in the ICU, with subsequent errors in recognizing patient safety issues. We hypothesized that a novel EHR simulation-based training exercise would decrease EHR use variability among intervention interns, irrespective of prior EHR experience. Objective: This study aims to understand the impact of a novel, short, high-fidelity, simulation-based EHR learning activity on the intern data gathering workflow and satisfaction. Methods: A total of 72 internal medicine interns across the 2018 and 2019 academic years underwent a dedicated EHR training session as part of a week-long boot camp early in their training. We collected data on previous EHR and ICU experience for all subjects. Training consisted of 1 hour of guided review of a high-fidelity, simulated ICU patient chart focusing on best navigation practices for data retrieval. Specifically, the activity focused on using high- and low-yield data visualization screens determined by expert consensus. The intervention group interns then had 20 minutes to review a new simulated patient chart before the group review. EHR screen navigation was captured using screen recording software and compared with data from existing ICU residents performing the same task on the same medical charts (N=62). Learners were surveyed immediately and 6 months after the activity to assess satisfaction and preferred EHR screen use. Results: Participants found the activity useful and enjoyable immediately and after 6 months. Intervention interns used more individual screens than reference residents (18 vs 20; P=.008), but the total number of screens used was the same (35 vs 38; P=.30). Significantly more intervention interns used the 10 most common screens (73% vs 45%; P=.001). Intervention interns used high-yield screens more often and low-yield screens less often than the reference residents, which are persistent on self-report 6 months later. Conclusions: A short, high-fidelity, simulation-based learning activity focused on provider-specific data gathering was found to be enjoyable and to modify navigation patterns persistently. This suggests that workflow-specific simulation-based EHR training throughout training is of educational benefit to residents. %M 33687339 %R 10.2196/25828 %U https://mededu.jmir.org/2021/1/e25828 %U https://doi.org/10.2196/25828 %U http://www.ncbi.nlm.nih.gov/pubmed/33687339 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e21196 %T Assessment of Diagnostic Competences With Standardized Patients Versus Virtual Patients: Experimental Study in the Context of History Taking %A Fink,Maximilian C %A Reitmeier,Victoria %A Stadler,Matthias %A Siebeck,Matthias %A Fischer,Frank %A Fischer,Martin R %+ Institute for Medical Education, University Hospital, LMU Munich, Pettenkoferstraße 8a, Munich, 80336, Germany, 49 089 4400 57428, maximilian.fink@yahoo.com %K clinical reasoning %K medical education %K performance-based assessment %K simulation %K standardized patient %K virtual patient %D 2021 %7 4.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Standardized patients (SPs) have been one of the popular assessment methods in clinical teaching for decades, although they are resource intensive. Nowadays, simulated virtual patients (VPs) are increasingly used because they are permanently available and fully scalable to a large audience. However, empirical studies comparing the differential effects of these assessment methods are lacking. Similarly, the relationships between key variables associated with diagnostic competences (ie, diagnostic accuracy and evidence generation) in these assessment methods still require further research. Objective: The aim of this study is to compare perceived authenticity, cognitive load, and diagnostic competences in performance-based assessment using SPs and VPs. This study also aims to examine the relationships of perceived authenticity, cognitive load, and quality of evidence generation with diagnostic accuracy. Methods: We conducted an experimental study with 86 medical students (mean 26.03 years, SD 4.71) focusing on history taking in dyspnea cases. Participants solved three cases with SPs and three cases with VPs in this repeated measures study. After each case, students provided a diagnosis and rated perceived authenticity and cognitive load. The provided diagnosis was scored in terms of diagnostic accuracy; the questions asked by the medical students were rated with respect to their quality of evidence generation. In addition to regular null hypothesis testing, this study used equivalence testing to investigate the absence of meaningful effects. Results: Perceived authenticity (1-tailed t81=11.12; P<.001) was higher for SPs than for VPs. The correlation between diagnostic accuracy and perceived authenticity was very small (r=0.05) and neither equivalent (P=.09) nor statistically significant (P=.32). Cognitive load was equivalent in both assessment methods (t82=2.81; P=.003). Intrinsic cognitive load (1-tailed r=−0.30; P=.003) and extraneous load (1-tailed r=−0.29; P=.003) correlated negatively with the combined score for diagnostic accuracy. The quality of evidence generation was positively related to diagnostic accuracy for VPs (1-tailed r=0.38; P<.001); this finding did not hold for SPs (1-tailed r=0.05; P=.32). Comparing both assessment methods with each other, diagnostic accuracy was higher for SPs than for VPs (2-tailed t85=2.49; P=.01). Conclusions: The results on perceived authenticity demonstrate that learners experience SPs as more authentic than VPs. As higher amounts of intrinsic and extraneous cognitive loads are detrimental to performance, both types of cognitive load must be monitored and manipulated systematically in the assessment. Diagnostic accuracy was higher for SPs than for VPs, which could potentially negatively affect students’ grades with VPs. We identify and discuss possible reasons for this performance difference between both assessment methods. %M 33661122 %R 10.2196/21196 %U https://www.jmir.org/2021/3/e21196 %U https://doi.org/10.2196/21196 %U http://www.ncbi.nlm.nih.gov/pubmed/33661122 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 7 %N 1 %P e23370 %T A Web Platform (MOSAICO) to Design, Perform, and Assess Collaborative Clinical Scenarios for Medical Students: Viewpoint %A Guinez-Molinos,Sergio %A Gonzalez Díaz,Jaime %A Gomar Sancho,Carmen %A Espinoza,Paulina %A Constenla,Gustavo %+ Laboratory of Biomedical Informatics, School of Medicine, Universidad de Talca, Campus San Miguel, Avda San Miguel S/N, Talca, 3460000, Chile, 56 712200200, sguinez@utalca.cl %K collaborative clinical simulation %K electronic simulation record %K medical students %K medical education %K MOSAICO %D 2021 %7 26.1.2021 %9 Viewpoint %J JMIR Med Educ %G English %X Background: The collaborative clinical simulation (CCS) model is a structured method for the development and assessment of clinical competencies through small groups working collaboratively in simulated environments. From 2016 onward, the CCS model has been applied successfully among undergraduate and graduate medical students from the Universidad de Talca, Chile; the Universität de Barcelona, Spain; and the Universidad de Vic-Manresa, Spain. All the templates for building the clinical cases and the assessment instruments with CCS were printed on paper. Considering the large number of CCS sessions and the number of participating students that are required throughout the medical degree curriculum, it is impossible to keep an organized record when the instruments are printed on paper. Moreover, with the COVID-19 pandemic, web platforms have become important as safe training environments for students and medical faculties; this new educational environment should include the consolidation and adaptation of didactic sessions that create and use available virtual cases and use different web platforms. Objective: The goal of this study is to describe the design and development of a web platform that was created to strengthen the CCS model. Methods: The design of the web platform aimed to support each phase of the CCS by incorporating functional requirements (ie, features that the web platform will be able to perform) and nonfunctional requirements (ie, how the web platform should behave) that are needed to run collaborative sessions. The software was developed under the Model-View-Controller architecture to separate the views from the data model and the business logic. Results: MOSAICO is a web platform used to design, perform, and assess collaborative clinical scenarios for medical students. MOSAICO has four modules: educational design, students’ collaborative design, collaborative simulation, and collaborative debriefing. The web platform has three different user profiles: academic simulation unit, teacher, and student. These users interact under different roles in collaborative simulations. MOSAICO enables a collaborative environment, which is connected via the internet, to design clinical scenarios guided by the teacher and enables the use of all data generated to be discussed in the debriefing session with the teacher as a guide. The web platform is running at the Universidad de Talca in Chile and is supporting collaborative simulation activities via the internet for two medical courses: (1) Semiology for third-year students (70 students in total) and (2) Medical Genetics for fifth-year students (30 students in total). Conclusions: MOSAICO is applicable within the CCS model and is used frequently in different simulation sessions at the Universidad de Talca, where medical students can work collaboratively via the internet. MOSAICO simplifies the application and reuse of clinical simulation scenarios, allowing its use in multiple simulation centers. Moreover, its applications in different courses (ie, a large part of the medical curriculum) support the automatic tracking of simulation activities and their assessment. %M 33496676 %R 10.2196/23370 %U http://mededu.jmir.org/2021/1/e23370/ %U https://doi.org/10.2196/23370 %U http://www.ncbi.nlm.nih.gov/pubmed/33496676 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18768 %T Learning Impact of a Virtual Brain Electrical Activity Simulator Among Neurophysiology Students: Mixed-Methods Intervention Study %A Björn,Marko Henrik %A Laurila,Jonne MM %A Ravyse,Werner %A Kukkonen,Jari %A Leivo,Sanna %A Mäkitalo,Kati %A Keinonen,Tuula %+ School of Applied Educational Science and Teacher Education, Joensuu, University of Eastern Finland, Futura, Yliopistonkatu 7, Joensuu, PL 111, Finland, 358 0400587693, marko.bjorn@turkuamk.fi %K virtual simulation %K electroencephalography %K theoretical knowledge %K neurophysiology %K brain activity %K psychomotor %D 2020 %7 30.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual simulation is the re-creation of reality depicted on a computer screen. It offers the possibility to exercise motor and psychomotor skills. In biomedical and medical education, there is an attempt to find new ways to support students’ learning in neurophysiology. Traditionally, recording electroencephalography (EEG) has been learned through practical hands-on exercises. To date, virtual simulations of EEG measurements have not been used. Objective: This study aimed to examine the development of students’ theoretical knowledge and practical skills in the EEG measurement when using a virtual EEG simulator in biomedical laboratory science in the context of a neurophysiology course. Methods: A computer-based EEG simulator was created. The simulator allowed virtual electrode placement and EEG graph interpretation. The usefulness of the simulator for learning EEG measurement was tested with 35 participants randomly divided into three equal groups. Group 1 (experimental group 1) used the simulator with fuzzy feedback, group 2 (experimental group 2) used the simulator with exact feedback, and group 3 (control group) did not use a simulator. The study comprised pre- and posttests on theoretical knowledge and practical hands-on evaluation of EEG electrode placement. Results: The Wilcoxon signed-rank test indicated that the two groups that utilized a computer-based electrode placement simulator showed significant improvement in both theoretical knowledge (Z=1.79, P=.074) and observed practical skills compared with the group that studied without a simulator. Conclusions: Learning electrode placement using a simulator enhances students’ ability to place electrodes and, in combination with practical hands-on training, increases their understanding of EEG measurement. %M 33377872 %R 10.2196/18768 %U http://games.jmir.org/2020/4/e18768/ %U https://doi.org/10.2196/18768 %U http://www.ncbi.nlm.nih.gov/pubmed/33377872 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e21855 %T Health Care Providers’ Performance, Mindset, and Attitudes Toward a Neonatal Resuscitation Computer-Based Simulator: Empirical Study %A Cutumisu,Maria %A Ghoman,Simran K %A Lu,Chang %A Patel,Siddhi D %A Garcia-Hidalgo,Catalina %A Fray,Caroline %A Brown,Matthew R G %A Greiner,Russell %A Schmölzer,Georg M %+ Department of Educational Psychology, Faculty of Education, University of Alberta, 6-102 Education North, Edmonton, AB, T6G2G5, Canada, 1 7804925211, cutumisu@ualberta.ca %K infant %K newborn %K delivery room %K neonatal resuscitation %K performance %K neonatal resuscitation program %K serious games %K computer-based game simulation %K mindset %D 2020 %7 21.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Neonatal resuscitation involves a complex sequence of actions to establish an infant’s cardiorespiratory function at birth. Many of these responses, which identify the best action sequence in each situation, are taught as part of the recurrent Neonatal Resuscitation Program training, but they have a low incidence in practice, which leaves health care providers (HCPs) less prepared to respond appropriately and efficiently when they do occur. Computer-based simulators are increasingly used to complement traditional training in medical education, especially in the COVID-19 pandemic era of mass transition to digital education. However, it is not known how learners’ attitudes toward computer-based learning and assessment environments influence their performance. Objective: This study explores the relation between HCPs’ attitudes toward a computer-based simulator and their performance in the computer-based simulator, RETAIN (REsuscitation TrAINing), to uncover the predictors of performance in computer-based simulation environments for neonatal resuscitation. Methods: Participants were 50 neonatal HCPs (45 females, 4 males, 1 not reported; 16 respiratory therapists, 33 registered nurses and nurse practitioners, and 1 physician) affiliated with a large university hospital. Participants completed a demographic presurvey before playing the game and an attitudinal postsurvey after completing the RETAIN game. Participants’ survey responses were collected to measure attitudes toward the computer-based simulator, among other factors. Knowledge on neonatal resuscitation was assessed in each round of the game through increasingly difficult neonatal resuscitation scenarios. This study investigated the moderating role of mindset on the association between the perceived benefits of understanding the terminology used in the computer-based simulator, RETAIN, and their performance on the neonatal resuscitation tasks covered by RETAIN. Results: The results revealed that mindset moderated the relation between participants’ perceived terminology used in RETAIN and their actual performance in the game (F3,44=4.56, R2=0.24, adjusted R2=0.19; P=.007; estimate=–1.19, SE=0.38, t44=–3.12, 95% CI –1.96 to –0.42; P=.003). Specifically, participants who perceived the terminology useful also performed better but only when endorsing more of a growth mindset; they also performed worse when endorsing more of a fixed mindset. Most participants reported that they enjoyed playing the game. The more the HCPs agreed that the terminology in the tutorial and in the game was accessible, the better they performed in the game, but only when they reported endorsing a growth mindset exceeding the average mindset of all the participants (F3,44=6.31, R2=0.30, adjusted R2=0.25; P=.001; estimate=–1.21, SE=0.38, t44=−3.16, 95% CI –1.99 to –0.44; P=.003). Conclusions: Mindset moderates the strength of the relationship between HCPs’ perception of the role that the terminology employed in a game simulator has on their performance and their actual performance in a computer-based simulator designed for neonatal resuscitation training. Implications of this research include the design and development of interactive learning environments that can support HCPs in performing better on neonatal resuscitation tasks. %M 33346741 %R 10.2196/21855 %U http://games.jmir.org/2020/4/e21855/ %U https://doi.org/10.2196/21855 %U http://www.ncbi.nlm.nih.gov/pubmed/33346741 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e23254 %T Simulation Game Versus Multiple Choice Questionnaire to Assess the Clinical Competence of Medical Students: Prospective Sequential Trial %A Fonteneau,Tristan %A Billion,Elodie %A Abdoul,Cindy %A Le,Sebastien %A Hadchouel,Alice %A Drummond,David %+ Department of Paediatric Pulmonology and Allergology, University Hospital Necker-Enfants Malades, Assistance Publique - Hôpitaux de Paris, 149 rue de Sèvres, Paris, , France, 33 1 44 49 48 48, david.drummond@aphp.fr %K serious game %K simulation game %K assessment %K professional competence %K asthma %K pediatrics %D 2020 %7 16.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of simulation games (SG) to assess the clinical competence of medical students has been poorly studied. Objective: The objective of this study was to assess whether an SG better reflects the clinical competence of medical students than a multiple choice questionnaire (MCQ). Methods: Fifth-year medical students in Paris (France) were included and individually evaluated on a case of pediatric asthma exacerbation using three successive modalities: high-fidelity simulation (HFS), considered the gold standard for the evaluation of clinical competence, the SG Effic’Asthme, and an MCQ designed for the study. The primary endpoint was the median kappa coefficient evaluating the correlation of the actions performed by the students between the SG and HFS modalities and the MCQ and HFS modalities. Student satisfaction was also evaluated. Results: Forty-two students were included. The actions performed by the students were more reproducible between the SG and HFS modalities than between the MCQ and HFS modalities (P=.04). Students reported significantly higher satisfaction with the SG (P<.01) than with the MCQ modality. Conclusions: The SG Effic’Asthme better reflected the actions performed by medical students during an HFS session than an MCQ on the same asthma exacerbation case. Because SGs allow the assessment of more dimensions of clinical competence than MCQs, they are particularly appropriate for the assessment of medical students on situations involving symptom recognition, prioritization of decisions, and technical skills. Trial Registration: ClinicalTrials.gov NCT03884114; https://clinicaltrials.gov/ct2/show/NCT03884114 %M 33325833 %R 10.2196/23254 %U http://www.jmir.org/2020/12/e23254/ %U https://doi.org/10.2196/23254 %U http://www.ncbi.nlm.nih.gov/pubmed/33325833 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e17146 %T Interactive Clinical Avatar Use in Pharmacist Preregistration Training: Design and Review %A Thompson,Jessica %A White,Simon %A Chapman,Stephen %+ School of Pharmacy and Bioengineering, Keele University, Hornbeam Building, Keele, , United Kingdom, 44 1782 733983, j.f.thompson@keele.ac.uk %K virtual patient %K high-fidelity simulation training %K patient simulation %K pharmacy education %K pharmacy practice education %K virtual reality %D 2020 %7 6.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual patients are interactive computer-based simulations that are being increasingly used in modern health care education. They have been identified as tools that can provide experiential learning and assessment in a standardized and safe environment. However, the study of high-fidelity virtual patients such as interactive clinical avatars within pharmacy is limited. Objective: The aim of this paper is to describe the design and review of three interactive clinical avatar simulations as part of pharmacist preregistration training. Methods: A multistep design approach was taken to create interactive clinical avatar simulations on the topics of emergency hormonal contraception (EHC), calculation of renal function, and childhood illnesses. All case studies were reviewed by registered pharmacists to establish content and face validity. The EHC case study and data collection questionnaire were also reviewed by a purposive sample of preregistration trainees and newly qualified pharmacists. The questionnaire used Likert ranking statements and open-ended questions to obtain users’ feedback on the design, usability, and usefulness of the interactive clinical avatars as learning tools. Descriptive statistics and content analysis were undertaken on the data. Results: Ten preregistration trainees and newly qualified pharmacists reviewed the EHC interactive clinical avatars and data collection questionnaire. The data collection questionnaire was associated with a Cronbach alpha=.95, demonstrating good reliability. All three interactive clinical avatar simulations were reported as usable and appropriately designed for preregistration training. Users perceived they were developing skills and knowledge from the simulations. The high-fidelity nature of the avatars and relevance of the simulations to real-life practice were reported as aspects that encouraged the application of theory to practice. Improvements were suggested to ensure the simulations were more user-friendly. Conclusions: The design and creation of the interactive clinical avatar simulations was successful. The multistep review process ensured validity and reliability of the simulations and data collection questionnaire. The in-depth explanation of the design process and provision of a questionnaire may help widen the use and evaluation of interactive clinical avatars or other simulation tools in pharmacy education. The interactive clinical avatars were reported as novel learning tools that promoted experiential learning and allowed users to feel like they were engaging in real-life scenarios, thus developing transferable knowledge and skills. This may be potentially beneficial for many health care training courses as a way to provide standardized experiences promoting active learning and reflection. %M 33155983 %R 10.2196/17146 %U https://www.jmir.org/2020/11/e17146 %U https://doi.org/10.2196/17146 %U http://www.ncbi.nlm.nih.gov/pubmed/33155983 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19723 %T Use of a Low-Cost Portable 3D Virtual Reality Simulator for Psychomotor Skill Training in Minimally Invasive Surgery: Task Metrics and Score Validity %A Alvarez-Lopez,Fernando %A Maina,Marcelo Fabián %A Arango,Fernando %A Saigí-Rubió,Francesc %+ Faculty of Health Sciences, Universitat Oberta de Catalunya, Avinguda Tibidabo, 39-43, Barcelona, 08035, Spain, 34 933 263 622, fsaigi@uoc.edu %K simulation training %K minimally invasive surgical procedures %K medical education %K user-computer interface %K computer-assisted surgery %K Leap Motion Controller %D 2020 %7 27.10.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The high cost and low availability of virtual reality simulators in surgical specialty training programs in low- and middle-income countries make it necessary to develop and obtain sources of validity for new models of low-cost portable simulators that enable ubiquitous learning of psychomotor skills in minimally invasive surgery. Objective: The aim of this study was to obtain validity evidence for relationships to other variables, internal structure, and consequences of testing for the task scores of a new low-cost portable simulator mediated by gestures for learning basic psychomotor skills in minimally invasive surgery. This new simulator is called SIMISGEST-VR (Simulator of Minimally Invasive Surgery mediated by Gestures - Virtual Reality). Methods: In this prospective observational validity study, the authors looked for multiple sources of evidence (known group construct validity, prior videogaming experience, internal structure, test-retest reliability, and consequences of testing) for the proposed SIMISGEST-VR tasks. Undergraduate students (n=100, reference group), surgical residents (n=20), and experts in minimally invasive surgery (n=28) took part in the study. After answering a demographic questionnaire and watching a video of the tasks to be performed, they individually repeated each task 10 times with each hand. The simulator provided concurrent, immediate, and terminal feedback and obtained the task metrics (time and score). From the reference group, 29 undergraduate students were randomly selected to perform the tasks 6 months later in order to determine test-retest reliability. Results: Evidence from multiple sources, including strong intrarater reliability and internal consistency, considerable evidence for the hypothesized consequences of testing, and partial confirmation for relations to other variables, supports the validity of the scores and the metrics used to train and teach basic psychomotor skills for minimally invasive surgery via a new low-cost portable simulator that utilizes interaction technology mediated by gestures. Conclusions: The results obtained provided multiple sources of evidence to validate SIMISGEST-VR tasks aimed at training novices with no prior experience and enabling them to learn basic psychomotor skills for minimally invasive surgery. %M 33107833 %R 10.2196/19723 %U http://games.jmir.org/2020/4/e19723/ %U https://doi.org/10.2196/19723 %U http://www.ncbi.nlm.nih.gov/pubmed/33107833 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e21123 %T Lessons Learned From an Evaluation of Serious Gaming as an Alternative to Mannequin-Based Simulation Technology: Randomized Controlled Trial %A Benda,Natalie C %A Kellogg,Kathryn M %A Hoffman,Daniel J %A Fairbanks,Rollin J %A Auguste,Tamika %+ Women’s and Infants’ Services, MedStar Washington Hospital Center, 110 Irving St. NW, 5B-41, Washington, DC, 20010, United States, 1 202 877 8177, tamika.c.auguste@medstar.net %K simulation training %K continuing medical education %K obstetrics %D 2020 %7 28.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The use of new technology like virtual reality, e-learning, and serious gaming can offer novel, more accessible options that have been demonstrated to improve learning outcomes. Objective: The aim of this study was to compare the educational effectiveness of serious game–based simulation training to traditional mannequin-based simulation training and to determine the perceptions of physicians and nurses. We used an obstetric use case, namely electronic fetal monitoring interpretation and decision making, for our assessment. Methods: This study utilized a mixed methods approach to evaluate the effectiveness of the new, serious game–based training method and assess participants’ perceptions of the training. Participants were randomized to traditional simulation training in a center with mannequins or serious game training. They then participated in an obstetrical in-situ simulation scenario to assess their learning. Participants also completed a posttraining perceptions questionnaire. Results: The primary outcome measure for this study was the participants’ performance in an in-situ mannequin-based simulation scenario, which occurred posttraining following a washout period. No significant statistical differences were detected between the mannequin-based and serious game–based groups in overall performance, although the study was not sufficiently powered to conclude noninferiority. The survey questions were tested for significant differences in participant perceptions of the educational method, but none were found. Qualitative participant feedback revealed important areas for improvement, with a focus on game realism. Conclusions: The serious game training tool developed has potential utility in providing education to those without access to large simulation centers; however, further validation is needed to demonstrate if this tool is as effective as mannequin-based simulation. %M 32985993 %R 10.2196/21123 %U http://games.jmir.org/2020/3/e21123/ %U https://doi.org/10.2196/21123 %U http://www.ncbi.nlm.nih.gov/pubmed/32985993 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e20249 %T Learning With Virtual Reality in Nursing Education: Qualitative Interview Study Among Nursing Students Using the Unified Theory of Acceptance and Use of Technology Model %A Lange,Ann-Kathrin %A Koch,Jana %A Beck,Anastasia %A Neugebauer,Till %A Watzema,Frauke %A Wrona,Kamil J %A Dockweiler,Christoph %+ University of Bielefeld, Universitätsstr 25, Bielefeld, 33615, Germany, 49 521106 ext 5160, ann-kathrin.lange@uni-bielefeld.de %K virtual reality %K edutainment %K serious games %K education %K health care %K gamification %K anatomy %K digital game–based learning %K nursing %K nursing informatics %D 2020 %7 1.9.2020 %9 Original Paper %J JMIR Nursing %G English %X Background: Digital games–based learning is a method of using digital games to impart knowledge. Virtual reality (VR) programs are a practical application of this method. Due to demographic changes, the nursing profession will become increasingly important. These VR applications can be of use in training nurses for future professional challenges they may encounter. The continuous development of VR applications enables trainees to encounter simulated real life effectively and to experience increasingly concrete situations. This can be of great importance in nursing education, since 3-dimensionality enables a better visualization of many fields of activity and can prevent potential future errors. In addition to this learning effect, VR applications also bring an element of fun to learning. Objective: The aim of this qualitative research effort is to observe the degree of acceptance of VR applications by nursing students in Germany. Various factors, including social influences, performance expectations, and effort expectations, are taken into consideration. Methods: With a qualitative cohort study, the acceptance of nursing students towards VR applications in anatomy teaching was determined. The 12 participants were first asked to fill out a quantitative questionnaire on their sociodemographic characteristics and the extent to which they valued and liked using technology. The participants were then allowed to test the VR application themselves and were finally asked about their experience in a qualitative interview. For the collection of data and the analysis of results, the unified theory of acceptance and use of technology was used in this study. Results: Overall, the study shows that the interviewed persons rated the VR application quite positively. The greatest influence in this was the personal attitude towards technology; the higher this affinity is, the more useful the VR application appears. Social influences can also increase the participant’s own acceptance if peers have a positive attitude towards such applications. The study shows that the trainees' motivation to learn was increased by using VR. We believe this is because each trainee could learn individually and the VR application was perceived as an enjoyable activity. Nevertheless, the cost factor of implementing VR applications in nursing training is currently still an obstacle, as not every institution has such financial capacities. Conclusions: The extent to which the use of VR applications in the training of nursing staff is justified depends on the degree of personal acceptance. The collected results give good practice-oriented insight into the attitude of trainees towards VR. Many of the interviewed persons saw benefits in the use of VR technologies. As VR applications are constantly developing, it is necessary to conduct further studies on VR applications in nursing education and to include other possible disciplines in which these applications can be helpful. %M 34345791 %R 10.2196/20249 %U https://nursing.jmir.org/2020/1/e20249/ %U https://doi.org/10.2196/20249 %U http://www.ncbi.nlm.nih.gov/pubmed/34345791 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18633 %T Effect of Computer Debriefing on Acquisition and Retention of Learning After Screen-Based Simulation of Neonatal Resuscitation: Randomized Controlled Trial %A Michelet,Daphne %A Barre,Jessy %A Truchot,Jennifer %A Piot,Marie-Aude %A Cabon,Philippe %A Tesniere,Antoine %+ Ilumens Platform of Simulation in Healthcare, Université de Paris, 45 rue des Saints Pères, Paris, 75006, France, 33 326832537, daphnemichelet@gmail.com %K screen-based simulation %K debriefing %K neonatal resuscitation %K simulation %K medical education %K midwifery %K neonatal %D 2020 %7 11.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Debriefing is key in a simulation learning process. Objective: This study focuses on the impact of computer debriefing on learning acquisition and retention after a screen-based simulation training on neonatal resuscitation designed for midwifery students. Methods: Midwifery students participated in 2 screen-based simulation sessions, separated by 2 months, session 1 and session 2. They were randomized in 2 groups. Participants of the debriefing group underwent a computer debriefing focusing on technical skills and nontechnical skills at the end of each scenario, while the control group received no debriefing. In session 1, students participated in 2 scenarios of screen-based simulation on neonatal resuscitation. During session 2, the students participated in a third scenario. The 3 scenarios had an increasing level of difficulty, with the first representing the baseline level. Assessments included a knowledge questionnaire on neonatal resuscitation, a self-efficacy rating, and expert evaluation of technical skills as per the Neonatal Resuscitation Performance Evaluation (NRPE) score and of nontechnical skills as per the Anaesthetists’ Non-Technical Skills (ANTS) system. We compared the results of the groups using the Mann-Whitney U test. Results: A total of 28 midwifery students participated in the study. The participants from the debriefing group reached higher ANTS scores than those from the control group during session 1 (13.25 vs 9; U=47.5; P=.02). Their scores remained higher, without statistical difference during session 2 (10 vs 7.75; P=.08). The debriefing group had higher self-efficacy ratings at session 2 (3 vs 2; U=52; P=.02). When comparing the knowledge questionnaires, the significant baseline difference (13 for debriefing group vs 14.5 for control group, P=.05) disappeared at the end of session 1 and in session 2. No difference was found for the assessment of technical skills between the groups or between sessions. Conclusions: Computer debriefing seems to improve nontechnical skills, self-efficacy, and knowledge when compared to the absence of debriefing during a screen-based simulation. This study confirms the importance of debriefing after screen-based simulation. Trial Registration: ClinicalTrials.gov NCT03844009; https://clinicaltrials.gov/ct2/show/NCT03844009 %M 32780021 %R 10.2196/18633 %U http://games.jmir.org/2020/3/e18633/ %U https://doi.org/10.2196/18633 %U http://www.ncbi.nlm.nih.gov/pubmed/32780021 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18822 %T An Immersive Multi-User Virtual Reality for Emergency Simulation Training: Usability Study %A Lerner,Dieter %A Mohr,Stefan %A Schild,Jonas %A Göring,Martin %A Luiz,Thomas %+ Fraunhofer Institute for Experimental Software Engineering, Research Program Digital Healthcare, Fraunhofer-Platz 1, Kaiserslautern, 67663, Germany, 49 631 6800 2148, Thomas.Luiz@iese.fraunhofer.de %K virtual reality %K educational virtual realities %K virtual patient simulation %K virtual emergency scenario %K simulation training %K head-mounted display %K immersive media %K training effectiveness %K presence experience %K anaphylaxis %K emergency medicine %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is increasingly used as simulation technology in emergency medicine education and training, in particular for training nontechnical skills. Experimental studies comparing teaching and learning in VR with traditional training media often demonstrate the equivalence or even superiority regarding particular variables of learning or training effectiveness. Objective: In the EPICSAVE (Enhanced Paramedic Vocational Training with Serious Games and Virtual Environments) project, a highly immersive room-scaled multi-user 3-dimensional VR simulation environment was developed. In this feasibility study, we wanted to gain initial insights into the training effectiveness and media use factors influencing learning and training in VR. Methods: The virtual emergency scenario was anaphylaxis grade III with shock, swelling of the upper and lower respiratory tract, as well as skin symptoms in a 5-year-old girl (virtual patient) visiting an indoor family amusement park with her grandfather (virtual agent). A cross-sectional, one-group pretest and posttest design was used to evaluate the training effectiveness and quality of the training execution. The sample included 18 active emergency physicians. Results: The 18 participants rated the VR simulation training positive in terms of training effectiveness and quality of the training execution. A strong, significant correlation (r=.53, P=.01) between experiencing presence and assessing training effectiveness was observed. Perceived limitations in usability and a relatively high extraneous cognitive load reduced this positive effect. Conclusions: The training within the virtual simulation environment was rated as an effective educational approach. Specific media use factors appear to modulate training effectiveness (ie, improvement through “experience of presence” or reduction through perceived limitations in usability). These factors should be specific targets in the further development of this VR simulation training. %M 32735548 %R 10.2196/18822 %U https://games.jmir.org/2020/3/e18822 %U https://doi.org/10.2196/18822 %U http://www.ncbi.nlm.nih.gov/pubmed/32735548 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e18983 %T Simulation Modeling as a Novel and Promising Strategy for Improving Success Rates With Research Funding Applications: A Constructive Thought Experiment %A McLean,Allen %A McDonald,Wade %A Goodridge,Donna %+ College of Medicine, University of Saskatchewan, 5D40 Health Sciences Building, 107 Wiggins Road, Saskatoon, SK, , Canada, 1 604 809 0919, allen.mclean@usask.ca %K simulation modeling %K computational science %K funding application %K grant funding %K grant writing %K nursing %K research %K thought experiment %K persuasive technology %K peripheral vascular disease %D 2020 %7 30.7.2020 %9 Viewpoint %J JMIR Nursing %G English %X Writing a successful grant or other funding applications is a requirement for continued employment, promotion, and tenure among nursing faculty and researchers. Writing successful applications is a challenging task, with often uncertain results. The inability to secure funding not only threatens the ability of nurse researchers to conduct relevant health care research but may also negatively impact their career trajectories. Many individuals and organizations have offered advice for improving success with funding applications. While helpful, those recommendations are common knowledge and simply form the basis of any well-considered, well-formulated, and well-written application. For nurse researchers interested in taking advantage of innovative computational methods and leading-edge analytical techniques, we propose adding the results from computer-based simulation modeling experiments to funding applications. By first conducting a research study in a virtual space, nurse researchers can refine their study design, test various assumptions, conduct experiments, and better determine which elements, variables, and parameters are necessary to answer their research question. In short, simulation modeling is a learning tool, and the modeling process helps nurse researchers gain additional insights that can be applied in their real-world research and used to strengthen funding applications. Simulation modeling is well-suited for answering quantitative research questions. Still, the design of these models can benefit significantly from the addition of qualitative data and can be helpful when simulating the results of mixed methods studies. We believe this is a promising strategy for improving success rates with funding applications, especially among nurse researchers interested in contributing new knowledge supporting the paradigm shift in nursing resulting from advances in computational science and information technology. %M 34345787 %R 10.2196/18983 %U https://nursing.jmir.org/2020/1/e18983/ %U https://doi.org/10.2196/18983 %U http://www.ncbi.nlm.nih.gov/pubmed/34345787 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17491 %T Use of a Low-Cost Portable 3D Virtual Reality Gesture-Mediated Simulator for Training and Learning Basic Psychomotor Skills in Minimally Invasive Surgery: Development and Content Validity Study %A Alvarez-Lopez,Fernando %A Maina,Marcelo Fabián %A Saigí-Rubió,Francesc %+ Faculty of Health Sciences, Universitat Oberta de Catalunya, Avinguda Tibidabo, 39-43, Barcelona, 08035, Spain, 34 933263622, fsaigi@uoc.edu %K simulation training %K minimally invasive surgery %K user-computer interface %K operating rooms %K medical education %K computer-assisted surgery %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Simulation in virtual environments has become a new paradigm for surgeon training in minimally invasive surgery (MIS). However, this technology is expensive and difficult to access. Objective: This study aims first to describe the development of a new gesture-based simulator for learning skills in MIS and, second, to establish its fidelity to the criterion and sources of content-related validity evidence. Methods: For the development of the gesture-mediated simulator for MIS using virtual reality (SIMISGEST-VR), a design-based research (DBR) paradigm was adopted. For the second objective, 30 participants completed a questionnaire, with responses scored on a 5-point Likert scale. A literature review on the validity of the MIS training-VR (MIST-VR) was conducted. The study of fidelity to the criterion was rated using a 10-item questionnaire, while the sources of content-related validity evidence were assessed using 10 questions about the simulator training capacity and 6 questions about MIS tasks, and an iterative process of instrument pilot testing was performed. Results: A good enough prototype of a gesture-based simulator was developed with metrics and feedback for learning psychomotor skills in MIS. As per the survey conducted to assess the fidelity to the criterion, all 30 participants felt that most aspects of the simulator were adequately realistic and that it could be used as a tool for teaching basic psychomotor skills in laparoscopic surgery (Likert score: 4.07-4.73). The sources of content-related validity evidence showed that this study’s simulator is a reliable training tool and that the exercises enable learning of the basic psychomotor skills required in MIS (Likert score: 4.28-4.67). Conclusions: The development of gesture-based 3D virtual environments for training and learning basic psychomotor skills in MIS opens up a new approach to low-cost, portable simulation that allows ubiquitous learning and preoperative warm-up. Fidelity to the criterion was duly evaluated, which allowed a good enough prototype to be achieved. Content-related validity evidence for SIMISGEST-VR was also obtained. %M 32673217 %R 10.2196/17491 %U http://www.jmir.org/2020/7/e17491/ %U https://doi.org/10.2196/17491 %U http://www.ncbi.nlm.nih.gov/pubmed/32673217 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e18105 %T Simulation-Based Education for Staff Managing Aggression and Externalizing Behaviors in Children With Autism Spectrum Disorder in the Hospital Setting: Pilot and Feasibility Study Protocol for a Cluster Randomized Controlled Trial %A Mitchell,Marijke Jane %A Newall,Fiona Helen %A Sokol,Jennifer %A Williams,Katrina Jane %+ Department of Neurodevelopment and Disability, Royal Children's Hospital, 50 Flemington Road, Parkville, Melbourne, 3052, Australia, 61 3 9345 5898, marijke.mitchell@rch.org.au %K feasibility studies %K autism spectrum disorder %K intellectual disability %K high-fidelity simulation training %K pediatric nursing %K child %K adolescent %K aggression %D 2020 %7 4.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Children with autism spectrum disorder (ASD) frequently demonstrate aggression and externalizing behaviors in the acute care hospital environment. Pediatric acute care nursing staff are often not trained in managing aggression and, in particular, lack confidence in preventing and managing externalizing behaviors in children with ASD. High-fidelity simulation exercises will be used in this study to provide deliberate practice for acute care pediatric nursing staff in the management of aggressive and externalizing behaviors. Objective: The purpose of this study is to conduct a pilot and feasibility cluster randomized controlled trial (RCT) to evaluate the effectiveness of simulation-based education for staff in managing aggression and externalizing behaviors of children with ASD in the hospital setting. Methods: This study has a mixed design, with between-group and within-participant comparisons to explore the acceptability and feasibility of delivering a large-scale cluster RCT. The trial process, including recruitment, completion rates, contamination, and completion of outcome measures, will be assessed and reported as percentages. This study will assess the acceptability of the simulation-based training format for two scenarios involving an adolescent with autism, with or without intellectual disability, who displays aggressive and externalizing behaviors and the resulting change in confidence in managing clinical aggression. Two pediatric wards of similar size and patient complexity will be selected to participate in the study; they will be randomized to receive either simulation-based education plus web-based educational materials or the web-based educational materials only. Change in confidence will be assessed using pre- and posttraining surveys for bedside nursing staff exposed to the training and the control group who will receive the web-based training materials. Knowledge retention 3 months posttraining, as well as continued confidence and exposure to clinical aggression, will be assessed via surveys. Changes in confidence and competence will be compared statistically with the chi-square test using before-and-after data to compare the proportion of those who have high confidence between the two arms at baseline and at follow-up. The simulation-based education will be recorded with trained assessors reviewing participants’ abilities to de-escalate aggressive behaviors using a validated tool. This data will be analyzed using mean values and SDs to understand the variation in performance of individuals who undertake the training. Data from each participating ward will be collected during each shift for the duration of the study to assess the number of aggressive incidents and successful de-escalation for patients with ASD. Total change in Code Grey activations will also be assessed, with both datasets analyzed using descriptive statistics. Results: This study gained ethical approval from The Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC) on November 1, 2019 (HREC reference number: 56684). Data collection was completed in February 2020. Data analysis is due to commence with results anticipated by August 2020. Conclusions: We hypothesize that this study is feasible to be conducted as a cluster RCT and that simulation-based training will be acceptable for acute care pediatric nurses. We anticipate that the intervention ward will have increased confidence in managing clinical aggression in children with ASD immediately and up to 3 months posttraining. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000139976; http://www.ANZCTR.org.au/ACTRN12620000139976.aspx International Registered Report Identifier (IRRID): DERR1-10.2196/18105 %M 32495742 %R 10.2196/18105 %U http://www.researchprotocols.org/2020/6/e18105/ %U https://doi.org/10.2196/18105 %U http://www.ncbi.nlm.nih.gov/pubmed/32495742 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 6 %N 1 %P e14140 %T A Virtual 3D Dynamic Model of Caries Lesion Progression as a Learning Object for Caries Detection Training and Teaching: Video Development Study %A Lara,Juan Sebastian %A Braga,Mariana Minatel %A Zagatto,Carlos Gustavo %A Wen,Chao Lung %A Mendes,Fausto Medeiros %A Murisi,Pedroza Uribe %A Haddad,Ana Estela %+ Department of Cariology, Operative Dentistry and Dental Public Health, Indiana University School of Dentistry, 415 Lansing Street, 144C, Indianapolis, IN, 46202, United States, 1 3142745463, laraseb@iu.edu %K 3d virtual models %K dental education %K e-learning %K learning object %K caries %K cariology %D 2020 %7 22.5.2020 %9 Original Paper %J JMIR Med Educ %G English %X Background: In the last decade, 3D virtual models have been used for educational purposes in the health sciences, specifically for teaching human anatomy and pathology. These models provide an opportunity to didactically visualize key spatial relations that can be poorly understood when taught by traditional educational approaches. Caries lesion detection is a crucial process in dentistry that has been reported to be difficult to learn. One especially difficult aspect is linking clinical characteristics of the different severity stages with their histological features, which is fundamental for treatment decision-making. Objective: This project was designed to develop a virtual 3D digital model of caries lesion formation and progression to aid the detection of lesions at different severity stages as a potential complement to traditional lectures. Methods: Pedagogical planning, including identification of objectives, exploration of the degree of difficulty of caries diagnosis–associated topics perceived by dental students and lecturers, review of the literature regarding key concepts, and consultation of experts, was performed prior to constructing the model. An educational script strategy was created based on the topics to be addressed (dental tissues, biofilm stagnation areas, the demineralization process, caries lesion progression on occlusal surfaces, clinical characteristics related to different stages of caries progression, and histological correlations). Virtual 3D models were developed using the Virtual Man Project and refined using multiple 3D software applications. In the next phase, computer graphic modelling and previsualization were executed. After that, the video was revised and edited based on suggestions. Finally, explanatory subtitles were generated, the models were textured and rendered, and voiceovers in 3 languages were implemented. Results: We developed a 6-minute virtual 3D dynamic video in 3 languages (English, Spanish, and Brazilian Portuguese) intended for dentists and dental students to support teaching and learning of caries lesion detection. The videos were made available on YouTube; to date, they have received more than 100,000 views. Conclusions: Complementary pedagogical tools are valuable to support cariology education. This tool will be further tested in terms of utility and usability as well as user satisfaction in achieving the proposed objectives in specific contexts. %M 32441661 %R 10.2196/14140 %U http://mededu.jmir.org/2020/1/e14140/ %U https://doi.org/10.2196/14140 %U http://www.ncbi.nlm.nih.gov/pubmed/32441661 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e15762 %T Mobile App to Improve House Officers’ Adherence to Advanced Cardiac Life Support Guidelines: Quality Improvement Study %A Hejjaji,Vittal %A Malik,Ali O %A Peri-Okonny,Poghni A %A Thomas,Merrill %A Tang,Yuanyuan %A Wooldridge,David %A Spertus,John A %A Chan,Paul S %+ Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, University of Missouri Kansas City, 4401 Wornall Rd, Kansas City, MO, United States, 1 2162781685, hejjajiv@umkc.edu %K cardiac arrest %K advanced cardiac life support %K mHealth %K quality improvement %K medical education %D 2020 %7 19.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Effective and timely delivery of cardiac arrest interventions during in-hospital cardiac arrest resuscitation is associated with greater survival. Whether a mobile app that provides timely reminders of critical interventions improves adherence to Advanced Cardiovascular Life Support (ACLS) guidelines among house officers, who may lack experience in leading resuscitations, remains unknown. Objective: The aim of this study was to assess the impact of a commercially available, dynamic mobile app on house officers’ adherence to ACLS guidelines. Methods: As part of a quality improvement initiative, internal medicine house officers were invited to participate and randomized to lead 2 consecutive cardiac arrest simulations, one with a novel mobile app and one without a novel mobile app. All simulations included 4 cycles of cardiopulmonary resuscitation with different cardiac arrest rhythms and were video recorded. The coprimary end points were chest compression fraction and number of correct interventions in each simulation. The secondary end point was incorrect interventions, defined as interventions not indicated by the 2015 ACLS guidelines. Paired t tests compared performance with and without the mobile app. Results: Among 53 house officers, 26 house officers were randomized to lead the first simulation with the mobile app, and 27 house officers were randomized to do so without the app. Use of the mobile app was associated with a higher number of correct ACLS interventions (out of 7; mean 6.2 vs 5.1; absolute difference 1.1 [95% CI 0.6 to 1.6]; P<.001) as well as fewer incorrect ACLS interventions (mean 0.3 vs 1.0; absolute difference –0.7 [95% CI –0.3 to –1.0]; P<.001). Simulations with the mobile app also had a marginally higher chest compression fraction (mean 90.9% vs 89.0%; absolute difference 1.9% [95% CI 0.6% to 3.4%]; P=.007). Conclusions: This proof-of-concept study suggests that this novel mobile app may improve adherence to ACLS protocols, but its effectiveness on survival in real-world resuscitations remains unknown. %M 32427115 %R 10.2196/15762 %U https://mhealth.jmir.org/2020/5/e15762 %U https://doi.org/10.2196/15762 %U http://www.ncbi.nlm.nih.gov/pubmed/32427115 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17222 %T Construct Validity of a Serious Game for Laparoscopic Skills Training: Validation Study %A IJgosse,Wouter %A van Goor,Harry %A Rosman,Camiel %A Luursema,Jan-Maarten %+ Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, Netherlands, 31 24 3617612, Wouter.IJgosse@radboudumc.nl %K laparoscopy %K surgery %K training %K education %K serious game %K resident training %K skills development %K psychomotor skills %K simulation center %D 2020 %7 7.5.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Surgical residents underutilize opportunities for traditional laparoscopic simulation training. Serious gaming may increase residents’ motivation to practice laparoscopic skills. However, little is known about the effectiveness of serious gaming for laparoscopic skills training. Objective: The aim of this study was to establish construct validity for the laparoscopic serious game Underground. Methods: All study participants completed 2 levels of Underground. Performance for 2 novel variables (time and error) was compared between novices (n=65, prior experience <10 laparoscopic procedures), intermediates (n=26, prior experience 10-100 laparoscopic procedures), and experts (n=20, prior experience >100 laparoscopic procedures) using analysis of covariance. We corrected for gender and video game experience. Results: Controlling for gender and video game experience, the effects of prior laparoscopic experience on the time variable differed significantly (F2,106=4.77, P=.01). Both experts and intermediates outperformed novices in terms of task completion speed; experts did not outperform intermediates. A similar trend was seen for the rate of gameplay errors. Both gender (F1,106=14.42, P<.001 in favor of men) and prior video game experience (F1,106=5.20, P=.03 in favor of experienced gamers) modulated the time variable. Conclusions: We established construct validity for the laparoscopic serious game Underground. Serious gaming may aid laparoscopic skills development. Previous gaming experience and gender also influenced Underground performance. The in-game performance metrics were not suitable for statistical evaluation. To unlock the full potential of serious gaming for training, a more formal approach to performance metric development is needed. %M 32379051 %R 10.2196/17222 %U http://games.jmir.org/2020/2/e17222/ %U https://doi.org/10.2196/17222 %U http://www.ncbi.nlm.nih.gov/pubmed/32379051 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 4 %P e16363 %T Improving the Use of Simulation in Nursing Education: Protocol for a Realist Review %A Meum,Torbjørg Træland %A Slettebø,Åshild %A Fossum,Mariann %+ Department of Health and Nursing Science, University of Agder, Box 509, Grimstad, 4898, Norway, 47 94888747, torbjorg.t.meum@uia.no %K education %K nursing %K learning %K realist review %K simulation training %D 2020 %7 29.4.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Nursing education has evolved in line with societal needs, and simulation-based learning (SBL) is increasingly being used to bridge the gap between practice and education. Previous literature reviews have demonstrated the effectiveness of using SBL in nursing education. However, there is a need to explore how and why it works to expand the theoretical foundation of SBL. Realist reviews are a theory-based approach to synthesizing existing evidence on how complex programs work in particular contexts or settings. Objective: This review aims to understand how, why, and in what circumstances the use of simulation affects learning as part of the bachelor’s program in nursing. Methods: A realist review will be conducted in accordance with the realist template for a systematic review. In particular, we will identify and explore the underlying assumption of how SBL is supposed to work, that is, identify and explore program theories of SBL. The review will be carried out as an iterative process of searching, appraising, and synthesizing the evidence to uncover theoretical concepts that explain the causal effects of SBL. In the final section of the review, we will involve stakeholders in the Norwegian community in a web-based Delphi survey to ensure that the emerging theoretical framework derived from the published literature aligns with stakeholders’ experience in practice. Results: The Norwegian Centre for Research Data (project number 60415) has approved the study. We have performed an initial literature search, whereas quality appraisal and data extraction are ongoing processes. Conclusions: The final outcome of the review is anticipated to extend the theoretical foundation for using simulation as an integrated component of the bachelor’s program in nursing. Furthermore, the findings will be used to produce a briefing document containing guidance for national stakeholders in the community of simulation-based nursing education. Finally, the review findings will be disseminated in a peer-reviewed journal as well as national and international conferences. International Registered Report Identifier (IRRID): DERR1-10.2196/16363 %M 32347808 %R 10.2196/16363 %U http://www.researchprotocols.org/2020/4/e16363/ %U https://doi.org/10.2196/16363 %U http://www.ncbi.nlm.nih.gov/pubmed/32347808 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 1 %P e15349 %T Using String Metrics to Improve the Design of Virtual Conversational Characters: Behavior Simulator Development Study %A García-Carbajal,Santiago %A Pipa-Muniz,María %A Múgica,Jose Luis %+ Computer Science Department, Universidad de Oviedo, Campus de Viesques Office 1 b 15, Gijón, 33203, Spain, 34 985182487, sgarcia@uniovi.es %K spoken interaction %K string metrics %K virtual conversational characters %K serious games %K e-learning %D 2020 %7 27.2.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: An emergency waiting room is a place where conflicts often arise. Nervous relatives in a hostile, unknown environment force security and medical staff to be ready to deal with some awkward situations. Additionally, it has been said that the medical interview is the first diagnostic and therapeutic tool, involving both intellectual and emotional skills on the part of the doctor. At the same time, it seems that there is something mysterious about interviewing that cannot be formalized or taught. In this context, virtual conversational characters (VCCs) are progressively present in most e-learning environments. Objective: In this study, we propose and develop a modular architecture for a VCC-based behavior simulator to be used as a tool for conflict avoidance training. Our behavior simulators are now being used in hospital environments, where training exercises must be easily designed and tested. Methods: We define training exercises as labeled, directed graphs that help an instructor in the design of complex training situations. In order to increase the perception of talking to a real person, the simulator must deal with a huge number of sentences that a VCC must understand and react to. These sentences are grouped into sets identified with a common label. Labels are then used to trigger changes in the active node of the graph that encodes the current state of the training exercise. As a consequence, we need to be able to map every sentence said by the human user into the set it belongs to, in a fast and robust way. In this work, we discuss two different existing string metrics, and compare them to one that we use to assess a designed exercise. Results: Based on the similarities found between different sets, the proposed metric provided valuable information about ill-defined exercises. We also described the environment in which our programs are being used and illustrated it with an example. Conclusions: Initially designed as a tool for training emergency room staff, our software could be of use in many other areas within the same environment. We are currently exploring the possibility of using it in speech therapy situations. %M 32130121 %R 10.2196/15349 %U http://games.jmir.org/2020/1/e15349/ %U https://doi.org/10.2196/15349 %U http://www.ncbi.nlm.nih.gov/pubmed/32130121 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 5 %N 2 %P e13568 %T Introduction of Ultrasound Simulation in Medical Education: Exploratory Study %A Hani,Selim %A Chalouhi,Gihad %A Lakissian,Zavi %A Sharara-Chami,Rana %+ Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, PO Box 11-0236 Riad El Solh 110 72020, Beirut,, Lebanon, 961 1350000 ext 5536, 7950, rsharara@aub.edu.lb %K medical education %K simulation training %K ultrasonography %D 2019 %7 26.9.2019 %9 Original Paper %J JMIR Med Educ %G English %X Background: Ultrasound is ubiquitous across all disciplines of medicine; it is one of the most commonly used noninvasive, painless diagnostic tools. However, not many are educated and trained well enough in its use. Ultrasound requires not only theoretical knowledge but also extensive practical experience. The simulated setting offers the safest environment for health care professionals to learn and practice using ultrasound. Objective: This study aimed to (1) assess health care professionals’ need for and enthusiasm toward practicing using ultrasound via simulation and (2) gauge their perception and acceptance of simulation as an integral element of ultrasound education in medical curricula. Methods: A day-long intervention was organized at the American University of Beirut Medical Center (AUBMC) to provide a free-of-charge interactive ultrasound simulation workshop—using CAE Vimedix high-fidelity simulator—for health care providers, including physicians, nurses, ultrasound technicians, residents, and medical students. Following the intervention, attendees completed an evaluation, which included 4 demographic questions and 16 close-ended questions based on a Likert scale agree-neutral-disagree. The results presented are based on this evaluation form. Results: A total of 41 participants attended the workshop (46% [19/41] physicians, 30% [12/41] residents, 19% [8/41] sonographers, and 5% [2/41] medical students), mostly from AUBMC (88%, 36/41), with an average experience of 2.27 (SD 3.45) years and 30 (SD 46) scans per attendee. Moreover, 15 out of 41 (36%) participants were from obstetrics and gynecology, 11 (27%) from internal medicine, 4 (10%) from pediatrics, 4 (10%) from emergency medicine, 2 (5%) from surgery and family medicine, and 5 (12%) were technicians. The majority of participants agreed that ultrasound provided a realistic setting (98%, 40/41) and that it allowed for training and identification of pathologies (88%, 36/41). Furthermore, 100% (41/41) of the participants agreed that it should be part of the curriculum either in medical school or residency, and most of the participants approved it for training (98%, 40/41) and teaching (98%, 40/41). Conclusions: All attendees were satisfied with the intervention. There was a positive perception toward the use of simulation for training and teaching medical students and residents in using ultrasound, and there was a definite need and enthusiasm for its integration into curricula. Simulation offers an avenue not only for teaching but also for practicing the ultrasound technology by both medical students and health care providers. %M 31573944 %R 10.2196/13568 %U http://mededu.jmir.org/2019/2/e13568/ %U https://doi.org/10.2196/13568 %U http://www.ncbi.nlm.nih.gov/pubmed/31573944 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e14160 %T Development of In-Browser Simulators for Medical Education: Introduction of a Novel Software Toolchain %A Šilar,Jan %A Polák,David %A Mládek,Arnošt %A Ježek,Filip %A Kurtz,Theodore W %A DiCarlo,Stephen E %A Živný,Jan %A Kofranek,Jiri %+ Institute of Pathological Physiology, First Faculty of Medicine, Charles University, U Nemocnice 5, Praha 2, Prague, 128-53, Czech Republic, 420 777686868, kofranek@gmail.com %K education %K physiology %K computer simulation %K modeling %K Web browser %K Web technologies %D 2019 %7 03.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Simulators used in teaching are interactive applications comprising a mathematical model of the system under study and a graphical user interface (GUI) that allows the user to control the model inputs and visualize the model results in an intuitive and educational way. Well-designed simulators promote active learning, enhance problem-solving skills, and encourage collaboration and small group discussion. However, creating simulators for teaching purposes is a challenging process that requires many contributors including educators, modelers, graphic designers, and programmers. The availability of a toolchain of user-friendly software tools for building simulators can facilitate this complex task. Objective: This paper aimed to describe an open-source software toolchain termed Bodylight.js that facilitates the creation of browser-based client-side simulators for teaching purposes, which are platform independent, do not require any installation, and can work offline. The toolchain interconnects state-of-the-art modeling tools with current Web technologies and is designed to be resilient to future changes in the software ecosystem. Methods: We used several open-source Web technologies, namely, WebAssembly and JavaScript, combined with the power of the Modelica modeling language and deployed them on the internet with interactive animations built using Adobe Animate. Results: Models are implemented in the Modelica language using either OpenModelica or Dassault Systèmes Dymola and exported to a standardized Functional Mock-up Unit (FMU) to ensure future compatibility. The C code from the FMU is further compiled to WebAssembly using Emscripten. Industry-standard Adobe Animate is used to create interactive animations. A new tool called Bodylight.js Composer was developed for the toolchain that enables one to create the final simulator by composing the GUI using animations, plots, and control elements in a drag-and-drop style and binding them to the model variables. The resulting simulators are stand-alone HyperText Markup Language files including JavaScript and WebAssembly. Several simulators for physiology education were created using the Bodylight.js toolchain and have been received with general acclaim by teachers and students alike, thus validating our approach. The Nephron, Circulation, and Pressure-Volume Loop simulators are presented in this paper. Bodylight.js is licensed under General Public License 3.0 and is free for anyone to use. Conclusions: Bodylight.js enables us to effectively develop teaching simulators. Armed with this technology, we intend to focus on the development of new simulators and interactive textbooks for medical education. Bodylight.js usage is not limited to developing simulators for medical education and can facilitate the development of simulators for teaching complex topics in a variety of different fields. %M 31271154 %R 10.2196/14160 %U https://www.jmir.org/2019/7/e14160 %U https://doi.org/10.2196/14160 %U http://www.ncbi.nlm.nih.gov/pubmed/31271154 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e12537 %T Finding the Right Blend of Technologically Enhanced Learning Environments: Randomized Controlled Study of the Effect of Instructional Sequences on Interprofessional Learning %A Liaw,Sok Ying %A Tan,Khoon Kiat %A Wu,Ling Ting %A Tan,Seng Chee %A Choo,Hyekyung %A Yap,John %A Lim,Sok Mui %A Wong,Lilian %A Ignacio,Jeanette %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Clinical Research Centre, 10 Medical Drive, Singapore, 117597, Singapore, 65 65167451, nurliaw@nus.edu.sg %K blended learning %K constructivism %K instructional sequence %K interprofessional learning %K simulation %K technologically-enhanced learning %K virtual reality %K web-based instruction %D 2019 %7 28.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: With the availability and capabilities of varied technologically enhanced learning activities, the blended learning approach has become increasingly popular in interprofessional education. The combined use of different technologically enhanced learning activities has not been fully examined, particularly to determine the effects of instructional sequences for effective learning outcomes. Objective: The objective of this study was to investigate whether the instructional sequences of a blended learning approach can improve students’ learning outcomes on interprofessional competencies. Methods: A randomized controlled study was conducted with 40 interprofessional health care teams. These teams undertook three technologically enhanced learning activities—Web-based instruction (WI), virtual reality (VR), and simulation exercise (SE)—after random assignment to three groups based on three different instructional sequences (WI-VR-SE, WI-SE-VR, and SE-WI-VR). Pretests and posttests were conducted to evaluate the students’ learning outcomes on interprofessional competencies. Results: A total of 198 participants from the three groups completed the questionnaires. All three groups reported significant improvement in their levels of self-efficacy (P<.05) and attitudes (P<.001) toward interprofessional team care about 1 month after the interprofessional learning activity. Although no significant difference was found (P=.06) between the WI-VR-SE and WI-SE-VR groups in the self-efficacy posttests, participants in the SE-WI-VR group reported significantly lower (P<.05) posttest scores than those in the WI-SE-VR group. The majority of the participants (137/198, 69.1%) selected the instructional sequence “WI-VR-SE” as their top preference. Conclusions: This study shows that the instructional sequence of a blended learning approach can have a significant impact on students’ learning outcomes. The learning of concepts from WI followed by problem-solving activity in the SE was found to be a more effective learning sequence than the reverse sequence. We recommend that future studies focus on scaffolding students’ learning when planning instructional sequences for technologically enhanced learning activities within blended learning environments. %M 31140432 %R 10.2196/12537 %U http://www.jmir.org/2019/5/e12537/ %U https://doi.org/10.2196/12537 %U http://www.ncbi.nlm.nih.gov/pubmed/31140432 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 2 %P e12713 %T Effect of an Augmented Reality Ultrasound Trainer App on the Motor Skills Needed for a Kidney Ultrasound: Prospective Trial %A Ebner,Florian %A De Gregorio,Amelie %A Schochter,Fabienne %A Bekes,Inga %A Janni,Wolfgang %A Lato,Krisztian %+ Helios Amper Klinikum, Klinikstrasse 15, Dachau, 85221, Germany, 49 8131 764298, dr.ebner@web.de %K ultrasound trainer %K mobile device %K mobile apps %K augmented reality %K kidney %K sensitivity and specificity %K ultrasonography %K education %K simulation training %K telemedicine %D 2019 %7 01.05.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Medical education is evolving from "learning by doing" to simulation-based hands-on tutorials. Objective: The aim of this prospective 2-armed study was to evaluate a newly developed augmented reality ultrasound app and its effect on educational training and diagnostic accuracy. Methods: We recruited 66 medical students and, using imaging and measuring a kidney as quality indicators, tested them on the time they needed for these tasks. Both groups used textbooks as preparation; in addition, the study group had access to a virtual ultrasound simulation app for mobile devices. Results: There was no significant difference between the study arms regarding age (P=.97), sex (P=.14), and previous ultrasound experience (P=.66). The time needed to complete the kidney measurements also did not differ significantly (P=.26). However, the results of the longitudinal kidney measurements differed significantly between the study and control groups, with larger, more realistic values in the study group (right kidney: study group median 105.3 mm, range 86.1-127.1 mm, control group median 92 mm, range 50.4-112.2 mm; P<.001; left kidney: study group median 100.3 mm, range 81.7-118.6 mm, control group median 85.3 mm, range 48.3-113.4 mm; P<.001). Furthermore, whereas all students of the study group obtained valid measurements, students of the control group did not obtain valid measurements of 1 or both kidneys in 7 cases. Conclusions: The newly developed augmented reality ultrasound simulator mobile app provides a useful add-on for ultrasound education and training. Our results indicate that medical students’ use of the mobile app for training purposes improved the quality of kidney measurements. %M 31042155 %R 10.2196/12713 %U http://games.jmir.org/2019/2/e12713/ %U https://doi.org/10.2196/12713 %U http://www.ncbi.nlm.nih.gov/pubmed/31042155 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e12251 %T Wearable Proximity Sensors for Monitoring a Mass Casualty Incident Exercise: Feasibility Study %A Ozella,Laura %A Gauvin,Laetitia %A Carenzo,Luca %A Quaggiotto,Marco %A Ingrassia,Pier Luigi %A Tizzoni,Michele %A Panisson,André %A Colombo,Davide %A Sapienza,Anna %A Kalimeri,Kyriaki %A Della Corte,Francesco %A Cattuto,Ciro %+ Data Science Laboratory, Institute for Scientific Interchange Foundation, Via Chisola 5, Torino, 10131, Italy, 39 3491973277, laura.ozella@gmail.com %K contact patterns %K contact networks %K wearable proximity sensors %K mass casualty incident %K simulation %K medical staff – patient interaction %K patients’ flow %D 2019 %7 26.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the past several decades, naturally occurring and man-made mass casualty incidents (MCIs) have increased in frequency and number worldwide. To test the impact of such events on medical resources, simulations can provide a safe, controlled setting while replicating the chaotic environment typical of an actual disaster. A standardized method to collect and analyze data from mass casualty exercises is needed to assess preparedness and performance of the health care staff involved. Objective: In this study, we aimed to assess the feasibility of using wearable proximity sensors to measure proximity events during an MCI simulation. In the first instance, our objective was to demonstrate how proximity sensors can collect spatial and temporal information about the interactions between medical staff and patients during an MCI exercise in a quasi-autonomous way. In addition, we assessed how the deployment of this technology could help improve future simulations by analyzing the flow of patients in the hospital. Methods: Data were obtained and collected through the deployment of wearable proximity sensors during an MCI functional exercise. The scenario included 2 areas: the accident site and the Advanced Medical Post, and the exercise lasted 3 hours. A total of 238 participants were involved in the exercise and classified in categories according to their role: 14 medical doctors, 16 nurses, 134 victims, 47 Emergency Medical Services staff members, and 27 health care assistants and other hospital support staff. Each victim was assigned a score related to the severity of his/her injury. Each participant wore a proximity sensor, and in addition, 30 fixed devices were placed in the field hospital. Results: The contact networks show a heterogeneous distribution of the cumulative time spent in proximity by the participants. We obtained contact matrices based on the cumulative time spent in proximity between the victims and rescuers. Our results showed that the time spent in proximity by the health care teams with the victims is related to the severity of the patient’s injury. The analysis of patients’ flow showed that the presence of patients in the rooms of the hospital is consistent with the triage code and diagnosis, and no obvious bottlenecks were found. Conclusions: Our study shows the feasibility of the use of wearable sensors for tracking close contacts among individuals during an MCI simulation. It represents, to our knowledge, the first example of unsupervised data collection—ie, without the need for the involvement of observers, which could compromise the realism of the exercise—of face-to-face contacts during an MCI exercise. Moreover, by permitting detailed data collection about the simulation, such as data related to the flow of patients in the hospital, such deployment provides highly relevant input for the improvement of MCI resource allocation and management. %M 31025944 %R 10.2196/12251 %U http://www.jmir.org/2019/4/e12251/ %U https://doi.org/10.2196/12251 %U http://www.ncbi.nlm.nih.gov/pubmed/31025944 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e261 %T Use of Simulator-Based Teaching to Improve Medical Students’ Knowledge and Competencies: Randomized Controlled Trial %A Fischer,Quentin %A Sbissa,Yannis %A Nhan,Pascal %A Adjedj,Julien %A Picard,Fabien %A Mignon,Alexandre %A Varenne,Olivier %+ Department of Cardiology, Cochin Hospital (Assistance Publique–Hôpitaux de Paris), Paris Descartes University, 27 Rue du Faubourg Saint Jacques, Paris, 75014, France, 33 158411662, olivier.varenne@aphp.fr %K education %K coronary angiography %K high fidelity simulation training %D 2018 %7 24.9.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Simulator-based teaching for coronary angiography (CA) is an attractive educational tool for medical students to improve their knowledge and skills. Its pedagogical impact has not been fully evaluated yet. Objective: The aim of this study was to compare traditional face-to-face teaching with a simulator-based teaching for the acquisition of coronary anatomy knowledge and CAs interpretation. Methods: A total of 118 medical school students in their fourth to sixth year were prospectively randomized in 2 groups: (1) a control teaching group (n=59, CONT group) and (2) a simulator group (using the Mentice VIST-Lab CA simulator; n=59, SIM group). The CONT group received a PowerPoint-based course, whereas the SIM group received a simulator-based course including the same information. After the course, all students were evaluated by 40 multiple choice questions (maximum of 100 points), including questions on coronary anatomy (part 1), angiographic projections (part 2), and real CAs interpretation (part 3). Satisfaction of the students was also evaluated by a simple questionnaire. Results: Student characteristics were identical in both the groups: 62/118 (52.5%) were female and age was 22.6 (SD 1.4) years. Moreover, 35.6% (42/118) were in their fourth year, 35.6% (42/118) were in the fifth year, and 28.8% (34/118) in the sixth year. During the evaluation, SIM students had higher global scores compared with CONT students, irrespective of their year of medical school (59.5 [SD 10.8] points vs 43.7 [SD 11.3] points, P<.001). The same observations were noted for each part of the test (36.9 [SD 6.6] points vs 29.6 [SD 6.9] points, P<.001; 5.9 [SD 3.0] points vs 3.1 [SD 2.8] points, P<.001; and 16.8 [SD 6.9] points vs 10.9 [SD 6.5] points, P<.001; for parts 1, 2, and 3, respectively). Student satisfaction was higher in the SIM group compared with the CONT group (98% vs 75%, P<.001). Conclusions: This study suggests that simulator-based teaching could potentially improve students’ knowledge of coronary anatomy, angiography projections, and interpretation of real clinical cases, suggesting better clinical skills. These results should encourage further evaluation of simulator-based teaching in other medical specialties and how they can translate into clinical practice. %M 30249587 %R 10.2196/jmir.9634 %U http://www.jmir.org/2018/9/e261/ %U https://doi.org/10.2196/jmir.9634 %U http://www.ncbi.nlm.nih.gov/pubmed/30249587 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e11061 %T The Modification of Vital Signs According to Nursing Students’ Experiences Undergoing Cardiopulmonary Resuscitation Training via High-Fidelity Simulation: Quasi-Experimental Study %A Fernández-Ayuso,David %A Fernández-Ayuso,Rosa %A Del-Campo-Cazallas,Cristino %A Pérez-Olmo,José Luis %A Matías-Pompa,Borja %A Fernández-Carnero,Josué %A Calvo-Lobo,Cesar %+ Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine Department, Rey Juan Carlos University, Avenida de Atenas s/n, Alcorcón, Madrid, 28922, Spain, 34 0034914888949, josuefernandezcarnero@gmail.com %K high-fidelity simulation training %K nursing students %K vital signs %K stress %K anxiety. %D 2018 %7 15.08.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: High-fidelity simulation represents a primary tool in nursing education, especially when hands-on practical training is involved. Objective: We sought to determine the influence of high-fidelity clinical simulation, applied during cardiopulmonary resuscitation (CPR) training, on blood pressure, heart rate, stress, and anxiety levels in 2 groups of nursing students. One group had experience in health contexts, whereas the other group had none. Methods: We performed a quasi-experimental study. Data were collected between May and June 2015 and included measurements of all the resting values, before and after participation in CPR clinical simulations regarding the 2 groups of university students (ie, with and without experience). Results: An increase in vital signs was observed in students after participating in a clinical simulation scenario, especially the heart rate. In all students, increased stress and anxiety levels were observed before the first simulation case scenario. Also, in all study groups, a decrease in vital signs, stress levels, and anxiety was observed throughout the study. Conclusions: Participation in high-fidelity simulation experiences has both physiological and psychological effects on students. %M 30111529 %R 10.2196/11061 %U http://games.jmir.org/2018/3/e11061/ %U https://doi.org/10.2196/11061 %U http://www.ncbi.nlm.nih.gov/pubmed/30111529 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e10693 %T Web-Based Immersive Patient Simulator as a Curricular Tool for Objective Structured Clinical Examination Preparation in Surgery: Development and Evaluation %A Chon,Seung-Hun %A Hilgers,Sabrina %A Timmermann,Ferdinand %A Dratsch,Thomas %A Plum,Patrick Sven %A Berlth,Felix %A Datta,Rabi %A Alakus,Hakan %A Schlößer,Hans Anton %A Schramm,Christoph %A Pinto dos Santos,Daniel %A Bruns,Christiane %A Kleinert,Robert %+ Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50937, Germany, 49 2214786254, robert.kleinert@uk-koeln.de %K immersive patient simulator %K simulator-based curriculum %K Objective Structured Clinical Examination %K artificial learning interface %D 2018 %7 04.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Objective Structured Clinical Examination is a standard method of testing declarative and process knowledge in clinical core competencies. It is desirable that students undergo Objective Structured Clinical Examination training before participating in the exam. However, establishing Objective Structured Clinical Examination training is resource intensive and therefore there is often limited practice time. Web-based immersive patient simulators such as ALICE (Artificial Learning Interface of Clinical Education) can possibly fill this gap as they allow for the training of complex medical procedures at the user’s individual pace and with an adaptable number of repetitions at home. ALICE has previously been shown to positively influence knowledge gain and motivation. Objective: Therefore, the aim of this study was to develop a Web-based curriculum that teaches declarative and process knowledge and prepares students for a real Objective Structured Clinical Examination station. Furthermore, we wanted to test the influence of ALICE on knowledge gain and student motivation. Methods: A specific curriculum was developed in order to implement the relevant medical content of 2 surgical Objective Structured Clinical Examination stations into the ALICE simulator framework. A total of 160 medical students were included in the study, where 100 students had access to ALICE and their performance was compared to 60 students in a control group. The simulator performance was validated on different levels and students’ knowledge gain and motivation were tested at different points during the study. Results: The curriculum was developed according to the Kern cycle. Four virtual clinical cases were implemented with different teaching methods (structured feedback, keynote speech, group discussion, and debriefing by a real instructor) in order to consolidate declarative and process knowledge. Working with ALICE had significant impact on declarative knowledge gain and Objective Structured Clinical Examination performance. Simulator validation was positive for face, content, construct, and predictive validity. Students showed high levels of motivation and enjoyed working with ALICE. Conclusions: ALICE offers Web-based training for Objective Structured Clinical Examination preparation and can be used as a selective didactic intervention as it has positive effect on knowledge gain and student motivation. %M 29973333 %R 10.2196/10693 %U http://games.jmir.org/2018/3/e10693/ %U https://doi.org/10.2196/10693 %U http://www.ncbi.nlm.nih.gov/pubmed/29973333 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 5 %P e138 %T Evaluating a Serious Gaming Electronic Medication Administration Record System Among Nursing Students: Protocol for a Pragmatic Randomized Controlled Trial %A Booth,Richard %A Sinclair,Barbara %A McMurray,Josephine %A Strudwick,Gillian %A Watson,Gavan %A Ladak,Hanif %A Zwarenstein,Merrick %A McBride,Susan %A Chan,Ryan %A Brennan,Laura %+ Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Western University, 1151 Richmond Street, FIMS and Nursing Building, Room 2333, London, ON, N6A 3K7, Canada, 1 5196612111 ext 86571, rbooth6@uwo.ca %K video games %K high fidelity simulation training %K nursing education %K medication errors %D 2018 %7 28.05.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Although electronic medication administration record systems have been implemented in settings where nurses work, nursing students commonly lack robust learning opportunities to practice the skills and workflow of digitalized medication administration during their formative education. As a result, nursing students’ performance in administering medication facilitated by technology is often poor. Serious gaming has been recommended as a possible intervention to improve nursing students’ performance with electronic medication administration in nursing education. Objective: The objectives of this study are to examine whether the use of a gamified electronic medication administration simulator (1) improves nursing students’ attention to medication administration safety within simulated practice, (2) increases student self-efficacy and knowledge of the medication administration process, and (3) improves motivational and cognitive processing attributes related to student learning in a technology-enabled environment. Methods: This study comprised the development of a gamified electronic medication administration record simulator and its evaluation in 2 phases. Phase 1 consists of a prospective, pragmatic randomized controlled trial with second-year baccalaureate nursing students at a Canadian university. Phase 2 consists of qualitative focus group interviews with a cross-section of nursing student participants. Results: The gamified medication administration simulator has been developed, and data collection is currently under way. Conclusions: If the gamified electronic medication administration simulator is found to be effective, it could be used to support other health professional simulated education and scaled more widely in nursing education programs. Trial Registration: ClinicalTrials.gov NCT03219151; https://clinicaltrials.gov/show/NCT03219151 (Archived by WebCite at http://www.webcitation.org/6yjBROoDt) Registered Report Identifier: RR1-10.2196/9601 %R 10.2196/resprot.9601 %U http://www.researchprotocols.org/2018/5/e138/ %U https://doi.org/10.2196/resprot.9601 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e8 %T Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study %A Motz,Patrick %A Gray,Megan %A Sawyer,Taylor %A Kett,Jennifer %A Danforth,Douglas %A Maicher,Kellen %A Umoren,Rachel %+ Division of Neonatology, Department of Pediatrics, University of Washington, 1959 NE Pacific St, Seattle, WA,, United States, 1 206 543 3675, rumoren@uw.edu %K prenatal counseling %K simulation %K ethics %D 2018 %7 11.05.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective: To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods: A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results: Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions: This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses. %M 29752249 %R 10.2196/games.9611 %U http://games.jmir.org/2018/2/e8/ %U https://doi.org/10.2196/games.9611 %U http://www.ncbi.nlm.nih.gov/pubmed/29752249 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 4 %N 1 %P e9 %T Instructional Video and Medical Student Surgical Knot-Tying Proficiency: Randomized Controlled Trial %A Bochenska,Katarzyna %A Milad,Magdy P %A DeLancey,John OL %A Lewicky-Gaupp,Christina %+ Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Prentice Women’s Hospital, 250 E Superior St Suite 05-2370, Chicago, IL, 60611, United States, 1 312 472 3874, kbochens@nm.org %K knot tying %K video %K proficiency %K medical student %D 2018 %7 12.04.2018 %9 Original Paper %J JMIR Med Educ %G English %X Background: Many senior medical students lack simple surgical and procedural skills such as knot tying. Objective: The aim of this study was to determine whether viewing a Web-based expert knot-tying training video, in addition to the standard third-year medical student curriculum, will result in more proficient surgical knot tying. Methods: At the start of their obstetrics and gynecology clerkship, 45 students were videotaped tying surgical knots for 2 minutes using a board model. Two blinded female pelvic medicine and reconstructive surgery physicians evaluated proficiency with a standard checklist (score range 0-16) and anchored scoring scale (range 0-20); higher numbers represent better skill. Students were then randomized to either (1) expert video (n=26) or (2) nonvideo (n=24) groups. The video group was provided unlimited access to an expert knot-tying instructional video. At the completion of the clerkship, students were again videotaped and evaluated. Results: At initial evaluation, preclerkship cumulative scores (range 0-36) on the standard checklist and anchored scale were not significantly different between the nonvideo and video groups (mean 20.3, SD 7.1 vs mean 20.2, SD 9.2, P=.90, respectively). Postclerkship scores improved in both the nonvideo and video groups (mean 28.4, SD 5.4, P<.001 and mean 28.7, SD 6.5, P=.004, respectively). Increased knot board practice was significantly correlated with higher postclerkship scores on the knot-tying task, but only in the video group (r=.47, P<.05). Conclusions: The addition of a Web-based expert instructional video to a standard curriculum, coupled with knot board practice, appears to have a positive impact on medical student knot-tying proficiency. %M 29650503 %R 10.2196/mededu.9068 %U http://mededu.jmir.org/2018/1/e9/ %U https://doi.org/10.2196/mededu.9068 %U http://www.ncbi.nlm.nih.gov/pubmed/29650503 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 3 %N 1 %P e2 %T An Interactive Simulation to Change Outcome Expectancies and Intentions in Adults With Type 2 Diabetes: Within-Subjects Experiment %A Gibson,Bryan %A Yingling,Leah %A Bednarchuk,Alisa %A Janamatti,Ashwini %A Oakley-Girvan,Ingrid %A Allen,Nancy %+ Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Salt Lake City, UT, 84108, United States, 1 801 585 0929, Bryan.Gibson@utah.edu %K diabetes mellitus, type 2 %K computer simulation %K beliefs %K intention %D 2018 %7 09.01.2018 %9 Original Paper %J JMIR Diabetes %G English %X Background: Computerized simulations are underutilized to educate or motivate patients with chronic disease. Objective: The aim of this study was to test the efficacy of an interactive, personalized simulation that demonstrates the acute effect of physical activity on blood glucose. Our goal was to test its effects on physical activity-related outcome expectancies and behavioral intentions among adults with type 2 diabetes mellitus (T2DM). Methods: In this within-subjects experiment, potential participants were emailed a link to the study website and directed through 7 tasks: (1) consent; (2) demographics, baseline intentions, and self-reported walking; (3) orientation to the diurnal glucose curve; (4) baseline outcome expectancy, measured by a novel drawing task in which participants use their mouse to draw the expected difference in the diurnal glucose curve if they had walked; (5) interactive simulation; (6) postsimulation outcome expectancy measured by a second drawing task; and (7) final measures of intentions and impressions of the website. To test our primary hypothesis that participants’ outcome expectancies regarding walking would shift toward the outcome presented in the interactive simulation, we used a paired t test to compare the difference of differences between the change in area under the curve in the simulation and participants’ two drawings. To test whether intentions to walk increased, we used paired t tests. To assess the intervention’s usability, we collected both quantitative and qualitative data on participants’ perceptions of the drawing tasks and simulation. Results: A total of 2019 individuals visited the website and 1335 (566 males, 765 females, and 4 others) provided complete data. Participants were largely late middle-aged (mean=59.8 years; standard deviation=10.5), female 56.55% (755/1335), Caucasian 77.45% (1034/1335), lower income 64.04% (855/1335) t1334=3.4, P ≤.001). Our second hypothesis, that participants’ intentions to walk in the coming week would increase, was also supported; general intention (mean difference=0.31/7, t1001=10.8, P<.001) and minutes of walking last week versus planned for coming week (mean difference=33.5 min, t1334=13.2, P<.001) both increased. Finally, an examination of qualitative feedback and drawing task data suggested that some participants had difficulty understanding the website. This led to a post-hoc subset analysis. In this analysis, effects for our hypothesis regarding outcome expectancies were markedly stronger, suggesting that further work is needed to determine moderators of the efficacy of this simulation. Conclusions: A novel interactive simulation is efficacious in changing the outcome expectancies and behavioral intentions of adults with T2DM. We discuss applications of our results to the design of mobile health (mHealth) interventions. %M 30291077 %R 10.2196/diabetes.8069 %U http://diabetes.jmir.org/2018/1/e2/ %U https://doi.org/10.2196/diabetes.8069 %U http://www.ncbi.nlm.nih.gov/pubmed/30291077 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 4 %P e23 %T The Role of Transfer in Designing Games and Simulations for Health: Systematic Review %A Kuipers,Derek A %A Terlouw,Gijs %A Wartena,Bard O %A van 't Veer,Job TB %A Prins,Jelle T %A Pierie,Jean Pierre EN %+ NHL Stenden University of Applied Sciences, Rengerslaan 10, Leeuwarden, 8917 DD, Netherlands, 31 0646064240, kuipersd@nhl.nl %K transfer %K computer simulation %K video games %K serious games %K games for health %K fidelity %K abstract learning %K immersion %K metaphor %D 2017 %7 24.11.2017 %9 Review %J JMIR Serious Games %G English %X Background: The usefulness and importance of serious games and simulations in learning and behavior change for health and health-related issues are widely recognized. Studies have addressed games and simulations as interventions, mostly in comparison with their analog counterparts. Numerous complex design choices have to be made with serious games and simulations for health, including choices that directly contribute to the effects of the intervention. One of these decisions is the way an intervention is expected to lead to desirable transfer effects. Most designs adopt a first-class transfer rationale, whereas the second class of transfer types seems a rarity in serious games and simulations for health. Objective: This study sought to review the literature specifically on the second class of transfer types in the design of serious games and simulations. Focusing on game-like interventions for health and health care, this study aimed to (1) determine whether the second class of transfer is recognized as a road for transfer in game-like interventions, (2) review the application of the second class of transfer type in designing game-like interventions, and (3) assess studies that include second-class transfer types reporting transfer outcomes. Methods: A total of 6 Web-based databases were systematically searched by titles, abstracts, and keywords using the search strategy (video games OR game OR games OR gaming OR computer simulation*) AND (software design OR design) AND (fidelity OR fidelities OR transfer* OR behaviour OR behavior). The databases searched were identified as relevant to health, education, and social science. Results: A total of 15 relevant studies were included, covering a range of game-like interventions, all more or less mentioning design parameters aimed at transfer. We found 9 studies where first-class transfer was part of the design of the intervention. In total, 8 studies dealt with transfer concepts and fidelity types in game-like intervention design in general; 3 studies dealt with the concept of second-class transfer types and reported effects, and 2 of those recognized transfer as a design parameter. Conclusions: In studies on game-like interventions for health and health care, transfer is regarded as a desirable effect but not as a basic principle for design. None of the studies determined the second class of transfer or instances thereof, although in 3 cases a nonliteral transfer type was present. We also found that studies on game-like interventions for health do not elucidate design choices made and rarely provide design principles for future work. Games and simulations for health abundantly build upon the principles of first-class transfer, but the adoption of second-class transfer types proves scarce. It is likely to be worthwhile to explore the possibilities of second-class transfer types, as they may considerably influence educational objectives in terms of future serious game design for health. %M 29175812 %R 10.2196/games.7880 %U http://games.jmir.org/2017/4/e23/ %U https://doi.org/10.2196/games.7880 %U http://www.ncbi.nlm.nih.gov/pubmed/29175812 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 3 %P e30 %T Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study %A Pranaat,Robert %A Mohan,Vishnu %A O'Reilly,Megan %A Hirsh,Maxwell %A McGrath,Karess %A Scholl,Gretchen %A Woodcock,Deborah %A Gold,Jeffrey A %+ Pulmonary Critical Care, Oregon Health & Sciences University, 3181 SW Sam Jackson park rd, Portland, OR, 97239, United States, 1 5034181496, goldje@ohsu.edu %K simulation training %K documentation %K electronic health record %D 2017 %7 20.09.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes. Objective: The objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes’ transcribed notes in the EHR. Methods: From a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy. Results: All scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%. Conclusions: We created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency. %M 28931497 %R 10.2196/medinform.7883 %U http://medinform.jmir.org/2017/3/e30/ %U https://doi.org/10.2196/medinform.7883 %U http://www.ncbi.nlm.nih.gov/pubmed/28931497 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 8 %P e153 %T Simulation-Based Training of Non-Technical Skills in Colonoscopy: Protocol for a Randomized Controlled Trial %A Khan,Rishad %A Scaffidi,Michael A %A Walsh,Catharine M %A Lin,Peter %A Al-Mazroui,Ahmed %A Chana,Barinder %A Kalaichandran,Ruben %A Lee,Woojin %A Grantcharov,Teodor P %A Grover,Samir C %+ St. Michael's Hospital, Division of Gastroenterology, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada, 1 4168646060, samir.grover@utoronto.ca %K simulation %K colonoscopy %K non-technical skills %K skill acquisition %D 2017 %7 04.08.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Non-technical skills (NTS), such as communication and professionalism, contribute to the safe and effective completion of procedures. NTS training has previously been shown to improve surgical performance. Moreover, increases in NTS have been associated with improved clinical endoscopic performance. Despite this evidence, NTS training has not been tested as an intervention in endoscopy. Objective: The aim of this study is to evaluate the effectiveness of a simulation-based training (SBT) curriculum of NTS on novice endoscopists’ performance of clinical colonoscopy. Methods: Novice endoscopists were randomized to 2 groups. The control group received 4 hours of interactive didactic sessions on colonoscopy theory and 6 hours of SBT. Hours 5 and 6 of the SBT were integrated scenarios, wherein participants interacted with a standardized patient and nurse, while performing a colonoscopy on the virtual reality (VR) simulator. The NTS (intervention) group received the same teaching sessions but the last hour was focused on NTS teaching. The NTS group also reviewed a checklist of tasks relevant to NTS concepts prior to each integrated scenario case and was provided with dedicated feedback on their NTS performance during the integrated scenario practice. All participants were assessed at baseline, immediately after training, and 4 to 6 weeks post-training. The primary outcome measure is colonoscopy-specific performance in the clinical setting. Results: In total, 42 novice endoscopists completed the study. Data collection and analysis is ongoing. We anticipate completion of all assessments by August 2017. Data analysis, manuscript writing, and subsequent submission for publication is expected to be completed by December 2017. Conclusions: Results from this study may inform the implementation of NTS training into postgraduate gastrointestinal curricula. NTS curricula may improve attitudes towards patient safety and self-reflection among trainees. Moreover, enhanced NTS may lead to superior clinical performance and outcomes in colonoscopy. Trial Registration: Clinicaltrial.gov NCT02877420; https://www.clinicaltrials.gov/ct2/show/NCT02877420 (Archived by WebCite at http://www.webcitation.org/6rw94ubXX NCT02877420) %M 28778849 %R 10.2196/resprot.7690 %U http://www.researchprotocols.org/2017/8/e153/ %U https://doi.org/10.2196/resprot.7690 %U http://www.ncbi.nlm.nih.gov/pubmed/28778849 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 3 %N 1 %P e8 %T Simulation Training: Evaluating the Instructor’s Contribution to a Wizard of Oz Simulator in Obstetrics and Gynecology Ultrasound Training %A Katz,Aric %A Tepper,Ronnie %A Shtub,Avraham %+ Technion - Israel Institute of Technology, Industrial Engineering & Management, Technion, Technion City, Haifa, 3200003, Israel, 972 972 4 8294402, shtub@ie.technion.ac.il %K distance learning %K feedback %K simulation training %K evaluation research %D 2017 %7 21.04.2017 %9 Original Paper %J JMIR Med Educ %G English %X Background: Workplaces today demand graduates who are prepared with field-specific knowledge, advanced social skills, problem-solving skills, and integration capabilities. Meeting these goals with didactic learning (DL) is becoming increasingly difficult. Enhanced training methods that would better prepare tomorrow’s graduates must be more engaging and game-like, such as feedback based e-learning or simulation-based training, while saving time. Empirical evidence regarding the effectiveness of advanced learning methods is lacking. Objective quantitative research comparing advanced training methods with DL is sparse. Objectives: This quantitative study assessed the effectiveness of a computerized interactive simulator coupled with an instructor who monitored students’ progress and provided Web-based immediate feedback. Methods: A low-cost, globally accessible, telemedicine simulator, developed at the Technion—Israel Institute of Technology, Haifa, Israel—was used. A previous study in the field of interventional cardiology, evaluating the efficacy of the simulator to enhanced learning via knowledge exams, presented promising results of average scores varying from 94% after training and 54% before training (n=20) with P<.001. Two independent experiments involving obstetrics and gynecology (Ob-Gyn) physicians and senior ultrasound sonographers, with 32 subjects, were conducted using a new interactive concept of the WOZ (Wizard of OZ) simulator platform. The contribution of an instructor to learning outcomes was evaluated by comparing students’ knowledge before and after each interactive instructor-led session as well as after fully automated e-learning in the field of Ob-Gyn. Results from objective knowledge tests were analyzed using hypothesis testing and model fitting. Results: A significant advantage (P=.01) was found in favor of the WOZ training approach. Content type and training audience were not significant. Conclusions: This study evaluated the contribution of an integrated teaching environment using a computerized interactive simulator, with an instructor providing immediate Web-based immediate feedback to trainees. Involvement of an instructor in the simulation-based training process provided better learning outcomes that varied training content and trainee populations did not affect the overall learning gains. %M 28432039 %R 10.2196/mededu.6312 %U http://mededu.jmir.org/2017/1/e8/ %U https://doi.org/10.2196/mededu.6312 %U http://www.ncbi.nlm.nih.gov/pubmed/28432039 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e22 %T Cardiopulmonary Resuscitation Training by Avatars: A Qualitative Study of Medical Students’ Experiences Using a Multiplayer Virtual World %A Creutzfeldt,Johan %A Hedman,Leif %A Felländer-Tsai,Li %+ Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, K32, Karolinska University Hospital, Stockholm, 14186, Sweden, 46 8 585 82102, johan.creutzfeldt@ki.se %K avatars %K cardiopulmonary resuscitation %K educational technology %K medical students %K experiences %K multiplayer virtual worlds %K patient simulation %K virtual learning environments %D 2016 %7 16.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine. Objective: The objective of this study was to reach a better understanding of the learners’ reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR). Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students’ perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants. Results: Four categories characterizing the students’ experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning. Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance. %M 27986645 %R 10.2196/games.6448 %U http://games.jmir.org/2016/2/e22/ %U https://doi.org/10.2196/games.6448 %U http://www.ncbi.nlm.nih.gov/pubmed/27986645 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 2 %N 1 %P e8 %T A Critical Review of Mechanical Ventilation Virtual Simulators: Is It Time to Use Them? %A Lino,Juliana Arcanjo %A Gomes,Gabriela Carvalho %A Sousa,Nancy Delma Silva Vega Canjura %A Carvalho,Andrea K %A Diniz,Marcelo Emanoel Bezerra %A Viana Junior,Antonio Brazil %A Holanda,Marcelo Alcantara %+ Federal University of Ceara, Medicine, Federal University of Ceara, 4th floor (402), Aldeota, 1972 Silva Paulet St, Fortaleza, 60120-021, Brazil, 55 85 996241243, juarcanjolino@hotmail.com %K positive-pressure respiration %K medical education %K computer simulation %K learning %D 2016 %7 14.06.2016 %9 Original Paper %J JMIR Med Educ %G English %X Background: Teaching mechanical ventilation at the bedside with real patients is difficult with many logistic limitations. Mechanical ventilators virtual simulators (MVVS) may have the potential to facilitate mechanical ventilation (MV) training by allowing Web-based virtual simulation. Objective: We aimed to identify and describe the current available MVVS, to compare the usability of their interfaces as a teaching tool and to review the literature on validation studies. Methods: We performed a comparative evaluation of the MVVS, based on a literature/Web review followed by usability tests according to heuristic principles evaluation of their interfaces as performed by professional experts on MV. Results: Eight MVVS were identified. They showed marked heterogeneity, mainly regarding virtual patient's anthropomorphic parameters, pulmonary gas exchange, respiratory mechanics and muscle effort configurations, ventilator terminology, basic ventilatory modes, settings alarms, monitoring parameters, and design. The Hamilton G5 and the Xlung covered a broader number of parameters, tools, and have easier Web-based access. Except for the Xlung, none of the simulators displayed monitoring of arterial blood gases and alternatives to load and save the simulation. The Xlung obtained the greater scores on heuristic principles assessments and the greater score of easiness of use, being the preferred MVVS for teaching purposes. No strong scientific evidence on the use and validation of the current MVVS was found. Conclusions: There are only a few MVVS currently available. Among them, the Xlung showed a better usability interface. Validation tests and development of new or improvement of the current MVVS are needed. %M 27731850 %R 10.2196/mededu.5350 %U http://mededu.jmir.org/2016/1/e8/ %U https://doi.org/10.2196/mededu.5350 %U http://www.ncbi.nlm.nih.gov/pubmed/27731850 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 2 %P e37 %T Effectiveness of a Web-Based Simulation in Improving Nurses’ Workplace Practice With Deteriorating Ward Patients: A Pre- and Postintervention Study %A Liaw,Sok Ying %A Wong,Lai Fun %A Lim,Eunice Ya Ping %A Ang,Sophia Bee Leng %A Mujumdar,Sandhya %A Ho,Jasmine Tze Yin %A Mordiffi,Siti Zubaidah %A Ang,Emily Neo Kim %+ National University of Singapore, Level 2 Clinical Research Centre, Block MD 11, Singapore, , Singapore, 65 65167451, nurliaw@nus.edu.sg %K Web-based simulation %K clinical deterioration %K nursing education %K online learning %K transfer of learning %K nursing practice %D 2016 %7 19.02.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Nurses play an important role in detecting patients with clinical deterioration. However, the problem of nurses failing to trigger deteriorating ward patients still persists despite the implementation of a patient safety initiative, the Rapid Response System. A Web-based simulation was developed to enhance nurses’ role in recognizing and responding to deteriorating patients. While studies have evaluated the effectiveness of the Web-based simulation on nurses’ clinical performance in a simulated environment, no study has examined its impact on nurses’ actual practice in the clinical setting. Objective: The objective of this study was to evaluate the impact of Web-based simulation on nurses' recognition of and response to deteriorating patients in clinical settings. The outcomes were measured across all levels of Kirkpatrick’s 4-level evaluation model with clinical outcome on triggering rates of deteriorating patients as the primary outcome measure. Methods: A before-and-after study was conducted on two general wards at an acute care tertiary hospital over a 14-month period. All nurses from the two study wards who undertook the Web-based simulation as part of their continuing nursing education were invited to complete questionnaires at various time points to measure their motivational reaction, knowledge, and perceived transfer of learning. Clinical records on cases triggered by ward nurses from the two study wards were evaluated for frequency and types of triggers over a period of 6 months pre- and 6 months postintervention. Results: The number of deteriorating patients triggered by ward nurses in a medical general ward increased significantly (P<.001) from pre- (84/937, 8.96%) to postintervention (91/624, 14.58%). The nurses reported positively on the transfer of learning (mean 3.89, SD 0.49) from the Web-based simulation to clinical practice. A significant increase (P<.001) on knowledge posttest score from pretest score was also reported. The nurses also perceived positively their motivation (mean 3.78, SD 0.56) to engage in the Web-based simulation. Conclusions: This study provides evidence on the effectiveness of Web-based simulation in improving nursing practice when recognizing and responding to deteriorating patients. This educational tool could be implemented by nurse educators worldwide to address the educational needs of a large group of hospital nurses responsible for patients in clinical deterioration. %M 26895723 %R 10.2196/jmir.5294 %U http://www.jmir.org/2016/2/e37/ %U https://doi.org/10.2196/jmir.5294 %U http://www.ncbi.nlm.nih.gov/pubmed/26895723